**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: 1.Ensure Resident 1 and Resident 2's low air-loss mattress (LALM - a mattress composed of inflatable air cushions used to relieve pressure on body parts) was set to appropriate settings per Physician Orders. 2.Ensure staff used one sheet and one chux (an absorbent under pads or bed pads used to protect surfaces from incontinence or spills) on Resident 1's LALM as indicated in the facility's policy. These deficient practices placed Resident 1 and Resident 2 at risk for the development of pressure ulcers. During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 10/5/2022 with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 2's Assessment of Decubitus Ulcer (also known as pressure ulcer) Potential, dated 5/2/2025, the Assessment of Decubitus Ulcer Potential indicated a risk score of 29. The Assessment of Decubitus Ulcer Potential Residents indicated the higher the score, the greater the potential to develop decubitus ulcers. Residents with scores above 12 should be considered at risk. During a review of Resident 1's History and Physical (H&P), dated 5/6/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Care Plan on pressure ulcers, last revised on 5/11/2025, the Care Plan indicated the resident had potential for PU development. The Care Plan Interventions indicated to use pressure relieving device on bed with correct setting. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 1 was in persistent vegetative state (a condition where a person is awake but showing no signs of awareness) and no discernible consciousness. The MDS indicated Resident 1 was dependent on facility staff in rolling to the left and right side. During a concurrent observation, interview, and record review on 7/17/2025 at 1:45 p.m. with Registered Nurse (RN) 1, RN 1 stated LALM was an intervention for residents with PU or were at risk for developing PU. RN 1 stated Resident 1's LALM was observed with one fitted sheet, two layers of flat sheet, one cloth chux, and a baby diaper. RN 1 stated a LALM required one layer of flat sheet and one layer of chux. RN 1 stated Resident 1's LALM setting should be based on the resident's weight. Resident 1's LALM setting was observed at level five. RN 1 stated level five LALM setting was for residents that were 210 pounds (lbs - unit of measurement). Resident 1's Physician Orders, dated 4/2/2025, reviewed with RN 1, the Physician Orders indicated Resident 1's LALM pressure setting was ordered to be at 140 per the resident's weight of 140 lbs for skin management. RN 1 stated Resident 1's LALM setting should be at level three. RN 1 an incorrect LALM setting and more than two layers of linen between a resident and the LALM had the potential for Resident 1 to develop PU and worsening moisture-associated skin damage (MASD). During an interview on 7/17/2025 at 3:11 p.m. and concurrent record review of the facility-provided LALM manufacturer's guidelines (undated), reviewed with the Director of Nursing (DON), the manufacturer's guidelines indicated the weight in lbs with the equivalent initial comfort level setting of the LALM. The DON stated a LALM were provided for residents with PU and for residents at risk for developing PU. The DON stated a LALM required the use of one linen and one disposable chux. The DON stated the cloth chux used for Resident 1 was not disposable and had multiple layers. The DON stated multiple layers of linen prevented the air from circulating and had the potential to cause friction and result in PU. The DON stated Resident 1's LALM setting should be based on the resident's weight and the physician's orders. The DON stated an incorrect LALM setting had the potential for Resident 1 to develop PU. The DON stated the facility failed to ensure Resident 1's LALM setting was based on the resident's weight and physician's order. The DON stated the facility failed to ensure there were only two layers of linen between the LALM and Resident 1. During a review of the facility's policy and procedure (PnP) titled, Low Air Loss Mattress, last reviewed on 1/21/2025, the PnP indicated the LALM will be used for residents who have actual or potential for PU. The PnP indicated a physician or nurse practitioner's order will be obtained for the use of a LALM. The PnP indicated residents will be placed onto the LALM.the mattress may have one sheet and one chux placed on it only. During a review of Resident 2's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/22/2024 with diagnoses including chronic respiratory failure, anoxic brain damage, and anxiety disorder. During a review of Resident 2's Assessment of Decubitus Ulcer (also known as pressure ulcer) Potential, dated 1/27/2025, the Assessment of Decubitus Ulcer Potential indicated a risk score of 20. The Assessment of Decubitus Ulcer Potential Residents indicated the higher the score, the greater the potential to develop decubitus ulcers. Residents with scores above 12 should be considered at risk. During a review of Resident 2's Care Plan on pressure ulcers, last revised on 4/27/2025, the Care Plan indicated the resident had potential for PU development. The Care Plan Interventions indicated to use pressure relieving device on bed. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The MDS indicated Resident 2 was dependent on facility staff in rolling to the left and right side, sitting to lying, and lying to sitting mobility. During a concurrent observation, interview, and record review on 7/17/2025 at 1:56 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LALM were used to prevent PU and skin breakdowns. LVN 1 stated Resident 2's LALM setting should be based on the resident's weight. LVN 1 stated Resident 2's LALM setting was observed to be at 80 lbs. Resident 2's Physician Order, dated 6/6/2025, reviewed with LVN 1, the Physician Order indicated Resident 2's LALM pressure setting was ordered to be at 110 per the resident's weight of 100 lbs for skin management. LVN 1 stated Resident 2's LALM setting was inaccurate and should be at 110 per physician's order. LVN 1 stated inaccurate LALM setting had the potential for Resident 2 to develop PU. During an interview on 7/17/2025 at 3:11 p.m. and concurrent record review of the facility-provided LALM manufacturer's guidelines (undated), reviewed with the Director of Nursing (DON), the manufacturer's guidelines indicated the weight in lbs with the equivalent initial comfort level setting of the LALM. The DON stated a LALM were provided for residents with PU and for residents at risk for developing PU. The DON stated Resident 2's LALM setting should be based on the resident's weight and the physician's orders. The DON stated an incorrect LALM setting had the potential for Resident 2 to develop PU. The DON stated the facility failed to ensure Resident 2's LALM setting was based on the resident's weight and physician's order. During a review of the facility's PnP titled, Low Air Loss Mattress, last reviewed on 1/21/2025, the PnP indicated the LALM will be used for residents who have actual or potential for PU. The PnP indicated a physician or nurse practitioner's order will be obtained for the use of a LALM. The PnP indicated residents will be placed onto the LALM.the mattress may have one sheet and one chux placed on it only.

Based on interview and record review, the facility failed to provide the State Survey Agency (SSA) with a written report of the findings of the investigation of an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment that may result in physical harm, pain or mental anguish) within five working days of the incident for one of four sampled residents (Residents 1). This failure had the potential to place residents at risk of unidentified abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 1/26/2012, with diagnoses of hypertension (high blood pressure), tracheostomy (a surgical opening in the neck to keep the airway open), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 2/16/2025, the MDS indicated Resident 1 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 was dependent on eating, personal hygiene, upper and lower body dressing. During an interview on 5/15/2025 at 10:07 a.m. with the Infection Preventionist (IP), the IP stated the alleged staff to resident abuse incident happened on 5/5/2025, when Resident 1 ' s Representative reported that while providing care to Resident 1, Certified Nurse Assistant (CNA) 1 was yelling Open, open, open, at Resident 1. The IP stated he was assigned by the Administrator to conduct interviews with staff and residents regarding the incident as part of the facility ' s internal investigation of the alleged abuse. The IP stated he was working on typing the final report of the internal investigation which would be provided to the SSA. During an interview on 5/15/2025 at 12:47 p.m. with the Administrator, the Administrator stated thefacility submitted the Report of Suspected Dependent Adult/Elder Abuse to the SSA on 5/6/2025. The Administrator stated the purpose of the facility ' s internal investigation of the incident was to get perspective of the incident and support the SSA ' s role in the investigation. The Administrator stated the facility failed to provide the final written report of the facility ' s investigation to the SSA within five days of the alleged incident. The Administrator stated the failure had the potential to place residents at risk of abuse. During a review of the facility-provided policy and procedure titled, Alleged Abuse, Neglect and Involuntary Seclusion, Reporting of, last reviewed on 1/21/2025, the policy and procedure indicated, A thorough investigation will be conducted to ascertain all the events that allegedly occurred, and the R.P will be notified. A final written report will be submitted to Department of Health Services within 5 business days.

Based on interview and record review, the facility failed to provide services to residents by qualified persons in accordance with each resident's written plan of care for one of four sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 provided oral suctioning (a medical procedure where sections such as saliva or mucus are removed from the mouth using a suction device) to Resident 1. This failure had the potential to place Resident 1 at risk for aspiration (when secretions or other substances enter the lungs instead of the stomach) and injury. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 1/26/2012, with diagnoses of chronic respiratory failure (a long-term condition where the lungs are unable to adequately transfer oxygen from the air into the bloodstream), tracheostomy (a surgical opening in the neck to keep the airway open), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 2/16/2025, the MDS indicated Resident 1 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 was dependent on eating, oral hygiene, personal hygiene, upper and lower body dressing. During a review of Resident 1 ' s Care Plan (CP) for oxygen therapy related to chronic respiratory failure, last revised on 4/15/2025, the CP indicated Resident 1 would have no signs and symptoms of poor oxygen absorption with interventions to suction as needed by Licensed Vocational Nurses (LVN), Registered Nurses (RN), or Respiratory Therapists (RT). During a review of Resident 1 ' s CP for total assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), last revised on 5/5/2025, the CP indicated provision of oral hygiene every shift and when needed by an RN. During an interview on 5/15/2025 at 9:54 a.m. with CNA 1, CNA 1 stated on 5/5/2025 at approximately 8:30 p.m., CNA1 and CNA 2 were providing care to Resident 1 and CNA 1 noted secretions in Resident 1 ' s mouth. CNA 1 stated she placed the Yankauer (a tool used to suction oral secretions) suction tip inside Resident 1 ' s mouth to remove oral secretions. CNA 1 stated while providing oral suctioning Resident 1 bit the Yankauer and CNA 1 told Resident 1 to open her mouth several times to remove the Yankauer from Resident 1's mouth. CNA 1 stated she was not trained to provide oral suctioning. During an interview on 5/15/2025 at 3:23 p.m. with CNA 2, CNA 2 stated on 5/5/2025, at approximately 8:30 p.m., CNA 1 and CNA 2 were providing care to Resident 1. CNA 2 stated CNA 1 placed Yankauer in Resident 1 ' s mouth to suction secretions. CNA 2 stated CNAs are not trained to provide oral suctioning to residents. During an interview on 5/15/2025 at 4:08 p.m. with the Director of Nursing (DON), the DON stated CNA 1 should not have provided oral suctioning to Resident 1 and should have called licensed staff for assistance. The DON stated CNAs can suction around residents ' mouth and near the neck but should not provide oral suctioning. The DON stated Resident 1 was placed at risk of aspiration and developing oral skin breakdown. During a review of the facility-provided policy and procedure titled, Suctioning-Oral, last reviewed on 1/21/2025, the policy and procedure indicated, Purpose: To permit removal of secretions; maintain and clear oral cavity when Patient/Resident is unable to expectorate. Policy: Oral suctioning may be done by licensed clinical staff. CNAs, family members, and residents may suction secretion that are around the mouth and face.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report immediately not later than two hours an allegation of abuse to the State Survey Agency (SSA) for one of three sampled residents (Resident 1) when on 4/30/2025 at 2 p.m. Resident 1 reported to the Social Worker (SW) an unnamed certified nursing assistant (CNA) touched him (Resident 1) inappropriately. This abuse allegation was reported to the SSA on 5/1/2025 at 4:02 p.m. This deficient practice placed Resident 1 at risk for further abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including traumatic hemorrhage of cerebrum (a collection of blood forms within the brain following a traumatic brain injury), chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen), anemia (a deficiency of red blood cells), diabetes (a group of diseases that result in too much sugar in the blood), and hydrocephalus (a build-up of fluid in the cavities deep within the brain). During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 2/10/2025, indicated Resident 1 was cognitively intact (thinking, learning, and memory skills are functioning within the expected range for their age and other relevant factors). The MDS indicated Resident 1 required maximal assistance with eating, oral hygiene, dressing, and personal hygiene. During a concurrent interview and record review on 5/2/2025 at 10:29 a.m. with the Infection Preventionist Registered Nurse (IPRN), the Fax Call Report regarding the date and time the facility faxed the SOC 341 (form used to report suspected elder and dependent adult abuse) report regarding Resident 1's abuse allegation to the SSA was reviewed. The IPRN stated the Fax Call Report indicated the SOC 341 regarding Resident 1's allegation of abuse was sent to the SSA on 5/1/2025 at 4:02 p.m. The IPRN stated Resident 1 reported to the SW on 4/30/2025 at 2 p.m. that about a year ago a CNA (name not indicated) took Resident 1 to the shower and placed a finger in Resident 1's anus. During an interview with Resident 1 on 5/2/2025 at 1 p.m., Resident 1 stated that about one year ago, a staff member touched him (Resident 1) inappropriately while in the shower. Resident 1 stated, he does not know the name of the staff member and cannot give a description of the staff member. During a concurrent interview and record review on 5/2/2025 at 2 p.m. with SW, Resident 1's Social Services Director Progress Notes, dated 4/30/2025 at 2:49 p.m., was reviewed. The Progress Note indicated SW was made aware by Resident 1 that he 9Resident 1) was inappropriately touched by a staff member approximately one year ago when he (Resident 1) was first regaining consciousness (state of wakefulness, awareness, or alertness). The SW stated she notified the [NAME] President of Operations regarding Resident 1's allegation of abuse. The SW stated Resident 1 made the allegation of abuse on 4/30/2025 and they reported to the SSA the following day. The SW stated allegations of abuse must be reported within two hours. The SW stated she does not know why it was not reported immediately to the SSA. During an interview with [NAME] President of Operations (VPO) on 5/2/2025 at 2:30 p.m., the VPO stated the SW reported to her on 4/30/2025 that Resident 1 reported an allegation of being touched inappropriately by a staff member. The VPO stated she interviewed Resident 1 and he stated the incident happened a year ago while in the shower. The VPO stated Resident 1 could not provide a detailed description of the incident and who the staff member was. The VPO stated the allegation was not reported within two hours because Resident 1 did not have any injuries. The VPO stated since there was no injury, the report was made the following day. A review of the facility's Policy and Procedure titled, Alleged Abuse, Neglect, and Involuntary Seclusion, reporting of, revised on 4/2025, indicated allegations of abuse are reported as soon as possible in the absence of a shorter state time frame requirement, but no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review, the facility failed to inform one of three sampled residents (Resident 1), attending physician (MD) when there was a significant change (a change in the resident's physical, mental, or psychosocial status that causes either life-threatening conditions or clinical complications) in the resident's condition. Resident 1 had a Change of Condition (COC- a major decline in a resident's status) on 4/19/2025 when Resident 1 became tachycardia (a medical condition characterized by a rapid heart rate, typically defined as a resting heart rate of over 100 beats per minute) and had a low-grade temperature. This deficient practice had the potential for a delay in the care of Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/05/2022 and readmitted the resident on 4/16/2024 with diagnoses including chronic respiratory failure (a long-term condition where the lungs can't effectively deliver enough oxygen to the blood or remove enough carbon dioxide), anxiety disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and dependence on respiratory ventilator (a medical device to help support or replace breathing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/13/2025, the MDS indicated Resident 1 was comatose (a state of deep unconsciousness for a prolonged or indefinite period, especially as a result of severe injury or illness). The MDS indicated Resident 1 was dependent (helper does all of the effort) with oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. During a review of Resident 1's Progress Notes, dated 4/19/2025 at 4:57 p.m. indicated Resident 1 transferred to General Acute Care Hospital (GACH) 1 for tachycardia (condition where the heart beats faster than normal, typically over 100 beats per minute at rest) unrelieved with Ativan (medication used to treat anxiety) and a low-grade temperature per Responsible Party (RP) request. The RP was at Resident 1's side and was aware of transfer. During a concurrent record review and interview on 4/29/2025 at 3p.m. of Resident 1's chart with the Director of Staff Development (DSD), the DSD stated a Change of Condition is a form of communication that tells the reason why the resident was trasferred out and includes the doctor, the family, and the nursing staff. The DSD stated Resident 1's tachycardia on 4/19/2025 would require a COC form to be created. The DSD stated there was no COC done for Resident 1's tachycardia on 4/19/2025. The DSD stated if the staff are not completing a COC, then there can be a gap in communication, we will not know what the COC was about, and can miss communicating the COC to a specific entity. The DSD reviewed the facility Policy and Procedures titled, Reporting Changes in Conditions, and the DSD stated the P&P indicated the doctor needs to be notified and there was no documented evidence the doctor was notified regarding Resident 1's COC on 4/19/2025. During an interview on 4/29/2025 at 3:32 p.m. with the DSD, the DSD stated the COC form is created when the initial change in condition with the resident occurs, it will include the vitals, what the COC is for, who was notified, the doctor, and the family. The DSD stated the doctor must be notified immediately to be aware of the situation and to provide any additional orders, labs and or to transfer the resident. During a revie of the facility's P&P titled, Reporting Changes in Condition, last reviewed on 3/2024, the P&P indicated to ensure the appropriate and timely notification of changes in condition to a resident's family and responsible party and physician and or Family Nurse Practitioner. 1. The nursing staff will report significant changes in a resident's condition or status to the resident's family and or responsible party in a timely manner 2. The nursing staff will also report significant changes in resident condition in resident condition to the primary physician and or Family Nurse Practitioner.

Based on interview and record review, the facility failed to implement its policy and procedure for ensuring the reporting of an allegation of abuse for one of three sampled residents (Resident 1). Resident 1 alleged being physically abused (intentional act of causing injury or trauma to a person through bodily contact) by an employee (name not indicated), but the facility did not respond in investigating or reporting such allegation to the California Department of Public Health (CDPH - licensing and certification division). This deficient practice delayed the investigative process and placed Resident 1 at an increased risk for further distress such as physical harm, emotional pain, and further trauma associated with the allegation of abuse. Findings During a review of Resident 1's Record of Admission, the Record of admission indicated an admit date of 1/6/2024 with diagnoses including chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly), traumatic hemorrhage of cerebrum (a collection of blood in the brain due to traumatic injury to the head), and diabetes insipidus (a disorder affecting the body's ability to regulate water balance, leading to excessive thirst and urination). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/10/2024 indicated that Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making tasks were intact. During an interview with the Director of Staff Development (DSD) on 12/12/2024 at 2:14 p.m., the DSD stated that all staff are mandated (officially required) reporters for abuse. The DSD further stated that reporting of abuse is to be done immediately, or no later than two (2) hours to the local police, Long-term Care Ombudsman (an appointed official that investigates, reports, and helps settle complaints), and to CDPH. DSD indicated the importance of reporting to the investigative agencies is so the agencies can come and do a thorough investigation of the allegation. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 12/12/2024 at 3:40 p.m., Resident 1's Nursing Progress Notes dated 11/25/2024 at 6:54 p.m. were reviewed. The progress notes indicated Resident 1 alleged being hit by staff (name not indicated) two times on the jaw. The progress notes indicated that the Abuse coordinator was informed of the allegation of abuse. RN 1 stated that types of abuse include physical abuse. RN 1 stated the importance of reporting allegations of abuse is To investigate it, to ensure safety for the resident. If it is not reported, it can happen again, so it needs to be addressed so that it does not happen again. During an interview and record review with the Administrator (ADM) on 12/12/2024 at 4:11 p.m., Resident 1's progress notes dated 11/25/2024 at 6:54 p.m. were reviewed. The progress notes indicated the allegation of abuse and information of the allegation of abuse was provided to the abuse coordinator. The ADM stated not being the abuse coordinator (the [NAME] President of Operations is the abuse coordinator) for the facility. The ADM stated this was the first time hearing about Resident 1's allegation of abuse and was not able to provide the facility's investigation report for the allegation or proof of attempts to contact the outside investigative agencies. During a review of the facility-provided policy and procedure titled, Reporting of Alleged Abuse, Neglect and Involuntary Seclusion, with last revised date of 8/16/2022, indicated, Alleged Violation: Is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated yet and if verified, could be non-compliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of residential property. The policy stated that should any employee of the facility be apprised or witness an allegation of abuse as defined in this policy, the employee is charged with the responsibility of reporting the alleged incident immediately. All Licensed employees are considered Mandated Reporters; however, the facility requires that all employees report such information. A thorough investigation will be conducted to ascertain all the events that allegedly occurred. A final written report will be submitted to Department of Health Services within 5 business days. The investigation will be timely and will be given priority. Any authorities that need to be contacted; e.g., Police Department, Ombudsman will be contacted within 24 hours. The Department of Health will be contacted within 2 hours of the initial report. This notification will be the responsibility of the [NAME] President of Operations (Abuse Coordinator), the Administrator, or Director of Nursing/Assistant Director of Nursing.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by not following the physician's orders. This deficient practice had the potential to result in Resident 1's increase in blood pressure (BP- pressure of circulating blood against the walls of blood vessels). Findings: During a record review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted Resident 1 on 9/19/2024 with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition in which not enough oxygen passes the lungs into your blood), end stage renal disease (ESRD - irreversible kidney failure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review of Resident 1's History and Physical (H&P), dated 9/19/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a record review of Resident 1's care plan, dated 9/20/2024, on hypertension (high blood pressure), the care plan indicated an intervention to administer medication as ordered. During a record review of Resident 1's Physician Orders, dated 9/22/2024, the Physician Orders indicated hydralazine (medication used to treat high blood pressure) 25 milligrams (mg - metric unit of measurement, used for medication dosage and or amount) tablet by gastrostomy tube (g tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every eight hours. During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/1/2024, the MDS indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During a record review of Resident 1's Medication Record, dated 10/2024, the Medication Record indicated on 10/18/2024 at 2 p.m., hydralazine was blank. During an interview on 11/8/2024 at 10:09 a.m., with Registered Nurse 1 (RN 1), RN 1 stated nurses should sign the Medication Record after administering the medication. RN 1 stated if Medication Record was left blank, it means medication was not given. RN 1 stated resident can receive double dose of the medication if not signed that can cause a drop in resident's blood pressure. During an interview on 11/8/2024 at 11:43 a.m., with the Director of Nursing (DON), the DON stated if medication was not signed, it means it was not given. The DON stated nurses should sign the Medication Record after giving the medication to prevent medication error leading to a blood pressure drop. During a concurrent interview and record review on 11/8/2024 at 11:49 a.m., with the DON, the facility's policy and procedure (PP) titled, Medication Administration Techniques, dated 10/25/2023 and last reviewed on 1/18/2024, the PP indicated, Observe the Ten Medication Rights .6. Right Documentation. After passing medication. 1 Record or sign the Medication Record.

Based on interview and record review, the failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1). This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care. Findings: During a record review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted Resident 1 on 9/19/2024 with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition in which not enough oxygen passes the lungs into your blood), end stage renal disease (ESRD--irreversible kidney failure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review of Resident 1's History and Physical (H&P), dated 9/19/29024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/1/2024, the MDS indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During a record review of Resident 1's Physician Order, dated 10/26/2024, the Physician Order indicated the following orders: 1. Lisinopril (medication used to treat high blood pressure) five milligrams (mg- metric unit of measurement, used for medication dosage and or amount) tablet via gastrostomy tube (g tube -a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) one time now for hypertension (elevated blood pressure). 2. Captopril (medication used to treat high blood pressure) 25 mg via g tube every eight hours, hold for systolic blood pressure (sbp-pressure in the arteries when the heart beats) less than 110. During a record review of Resident 1's Nursing Narrative Notes dated 10/26/2024, the Nursing Narrative Notes indicated on 10/26/2024, at 9:10 a.m., Resident 1's blood pressure was 243/106 millimeter of mercury (mmHg - unit of measure) and clonidine (medication used to treat high blood pressure) was given. The Nursing Narrative Notes indicated at 10:10 a.m., Resident 1's blood pressure was at 219/85 mmHg and Registered Nurse 3 (RN 3) instructed Licensed vocational Nurse 3 (LVN 3) to administer lisinopril and captopril. The Nursing Narrative Notes indicated paramedics arrived at 11:52 a.m. and Resident 1 was transported to General Acute Care Hospital (GACH) at 12:10 p.m. During a record review of Resident 1's Medication Record, dated 10/26/2024, the Medication Record indicated lisinopril was left blank on 10/26/2024 and captopril was given at 10 p.m. During an interview on 11/8/2024, at 9:53 a.m., with LVN 3, LVN 3 stated he (LVN 3) had given the lisinopril and captopril to Resident 1 on 10/26/2024 before Resident 1 was transferred out to GACH but forgot to sign the Medication Record. LVN 3 stated if medication given was not documented it can cause medication error. During an interview on 11/8/2024, at 11:43 a.m., with the Director of Nursing (DON), the DON stated if medication was not signed, it means it was not given. The DON stated nurses should sign the Medication Record after giving the medication to prevent medication error. During a concurrent interview and record review on 11/8/2024, at 11:49 a.m., with the DON, facility's policy and procedure (PP) titled, Medication Error Policy and Record Completion, dated 3/2024, was reviewed. The PP indicated, The facility shall make every effort to ensure that an accurate, concise and complete health record is maintained in the facility. Correctable deficiencies shall be corrected, timely in accordance with the professional standards and practice. The DON stated residents medical records should be complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident was free from any significant medication error for one of three sampled residents (Resident 2) by not following the physicians order, by: 1. Failing to hold the midodrine (medication used to treat low blood pressure) six times on 10/2024. 2. Failed to administer the midodrine on [DATE], at 9 a.m. These deficient practices had the potential to result in significant increase in Resident 2's blood pressure. Findings: During a record review of Resident 2's Record of Admission, the Record of admission indicated the facility admitted Resident 2 on [DATE], with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition in which not enough oxygen passes the lungs into your blood), unspecified hypotension (low blood pressure) and down syndrome (a genetic condition where a person is born with an extra chromosome. This can affect how their brain and body develop). During a record review of Resident 2's Physician Order, dated [DATE], the Physician Order indicated midodrine 10 milligram (mg - metric unit of measurement, used for medication dosage and or amount) tablet via gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every 12 hours and hold for systolic blood pressure (sbp- pressure in the arteries when the heart beats) greater than 110. During a record review of Resident 2's History and Physical (H&P), dated [DATE], the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a record review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 2 was on persistent vegetative state (a chronic condition that occurs when someone is awake but shows no awareness of their surroundings, they may open their eyes, make sounds, or move, but they are unable to respond to their environment or follow simple commands). The MDS indicated Resident 2 was dependent to staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). a. During a concurrent interview and record review on [DATE], at 9:44 a.m., with the Director of Nursing (DON), Resident 2's Medication Record dated 10/2024, was reviewed. The Medication Record indicated midodrine was administered on the following dates and times: 1. [DATE], at 9 a.m., with blood pressure of 116/68 millimeter of mercury (mmHg - unit of measure) 2. [DATE], at 9 p.m., with blood pressure of 125/65 mmHg 3. [DATE], at 9 a.m., with blood pressure of 113/63 mmHg 4. [DATE], at 9 p.m., with blood pressure of 113/66 mmHg 5. [DATE], at 9 a.m., with blood pressure of 112/69 mmHg 6. [DATE], at 9 p.m., with blood pressure of 125/81 mmHg The DON stated nurses should have held the midodrine as per physician order not to administer for blood pressure greater than 110. The DON stated nurses should have followed the physician order. The DON stated Resident 2's blood pressure can increase that may result to cardiac problems (a range of conditions that affect the heart and blood vessels). b. During a concurrent interview and record review on [DATE], at 11:42 a.m., with the DON, Resident 2's Medication Record, dated 10/2023, was reviewed. The Medication Record indicated on [DATE], at 9 a.m., Resident 2's blood pressure was 105/71 mmHg and midodrine was not admistered. The DON stated LVN should have administered the midodrine as per physician order for blood pressure support. The DON stated Resident 2's blood pressure can drop because the midodrine was not given. During a concurrent interview and record review of facility's policy and procedure (PP) titled, Ten Medication Rights, dated 7/2022, and last reviewed on [DATE], the PP indicated, The purpose of this policy is to provide guidelines for Medication Patients' Rights .2. Right Medication -Read the medication label carefully and compare to the Medication Record .7. Right Reason-confirm the rational for the ordered medication. The DON stated nurses should read the medication label and compare with the physician order to prevent medication error. During a record review of facility's PP titled, Medication Pass via Gastrostomy tube or Jejunostomy tube (J tube-a soft, plastic tube that is surgically inserted into the small intestine to provide nutrition and hydration), dated 5/2020, and last reviewed on [DATE], the PP indicated, Follow the Ten Patients' Rights of giving medications. During a record review of facility's PP titled, Medication Administration Techniques, dated [DATE], and last reviewed on [DATE], the PP indicated, During the pass: . 2. Check any necessary parameters: blood pressure, heart rate and etcetera. 3. Dispense or prepare medications as per physician order. During a record review of facility's PP tilted, Medication Error Policy and Record Completion, dated 3/2024, the PP indicated, A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm or no harm while the medication is in the control of the health care professional. Types of Medication Errors; Medication errors are categorized along each functional step of the medication cycle: ordering, transcription, preparation, dispensing, administration, monitoring, equipment or environment and contributing factor. 1. Order Error - Types of ordering errors include inappropriate dose, illegible order, duplicate order, order not dated and timed, wrong patient, contraindication, verbal order misunderstood, wrong time, wrong frequency, wrong route, wrong duration, alert information bypassed or misunderstood, and nonstandard use of abbreviations. When a medication not available at the time for administration, the Charge Nurse or Primary Nurse may request an order for When available. 2. Transcription Error - Involves the orders that are manually transcribed onto the medical record. Types of transcription errors include wrong medication, wrong time, dose, frequency, duration, and rate. 3. Preparation and Dispensing Order -types of preparation and dispensing errors include inaccurate labeling, wrong quantity, wrong formulation, expired medication, refill errors, and delay in medication delivery. (Medications are not considered expired on the expiration date. They are considered expired on the following date after expiration on the medication label.) 4. Administration Error - Types of administration errors include wrong patient, dose, time, medication, route, rate, omission, and unauthorized dose given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) when Registered Nurse 4 (RN 4) did not don (put on) a gown while providing gastrostomy (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems) care for one of five sampled residents (Resident 5). 2. Ensure RN 4 sanitized her (RN 4) hands after wearing gloves, and before medication preparation for one of five sampled residents (Resident 6). These deficient practices had the potential to spread infections and illnesses among residents and staff. Findings: a. During a review of Resident 5's Record of Admission, the Record of admission indicated the facility admitted the resident on 7/26/2000 and readmitted the resident on 11/23/2018. During a review of Resident 5's Client Diagnosis Report, dated 11/23/2018, the Client Diagnosis Report indicated diagnoses that included chronic respiratory failure (inability to breathe properly or deeply enough), unspecified whether with hypoxia (low blood oxygen) or hypercapnia (a buildup of carbon dioxide {odorless gas that we breathe out when we exhale} in your bloodstream. During a review of Resident 5's History and Physical, dated 11/26/2023, the History and Physical indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/10/2024, the MDS indicated the resident was comatose (unconscious and not able to wake up). The MDS further indicated Resident 5 was dependent on staff for oral hygiene, toileting, dressing, and mobility. During a review of Resident 5's Physician's Orders, the Physician's Orders indicated flush feeding tube (delivers liquid nutrition and medication to people who are unable to eat or swallow normally) with 200 cubic centimeter (cc - standard unit of volume) of water every six hours, dated 7/6/2024. During a concurrent observation and interview on 11/8/2024 at 9:51 a.m., observed RN 1 provide GT care for Resident 5. Observed that RN 4 inside Resident 6 room wearing gloves and mask. RN 4 accessed Resident 5's GT, removed her gloves and leave the room without performing hand hygiene. Observe RN 4 went to medication cart and prepare Resident 6's medication. RN 4 stated she must wear a gown during GT site care for Resident 5 and perform hand hygiene after removing her gloves and before preparing Resident 6's medication. During a interview on 11/8/2024 at 10:34 a.m., Infection Preventionist (IP) stated RN 4 must wear gown before handling the GT of Resident 5 and perform hand hygiene after removing gloves because RN 4 could transmit microorganism to self and to other residents. During an interview on 11/8/2024 at 11:27 a.m., the Director of Nursing (DON) stated RN 4 must wear proper EBP attire before touching the resident to prevent cross contamination to other residents. During a review of the facility policy and procedure titled, Enhanced Barrier Precautions (EBP) 2024, last reviewed date of 1/18/2024, indicated to wear gowns, gloves, goggles, and mask while performing the following high contact task associated with the greatest risk for MDRO contamination of HCP hands, clothes, and the environment: A. Device care, for example, urinary catheter, feeding tube, tracheostomy, vascular catheter. b. During a review of Resident 6's Record of Admission, the Record of admission indicated the facility admitted the resident on 9/18/2024. During a review of Resident 6's Client Diagnosis Report, dated 10/3/2024, the Client Diagnosis Report indicated diagnoses that included chronic respiratory failure, unspecified whether with hypoxia or hypercapnia in your bloodstream. During a review of Resident 6's History and Physical, dated 10/4/2024, the History and Physical indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set, dated [DATE], the MDS further indicated the resident was dependent on staff for oral hygiene, toileting, dressing, and mobility. During a review of Resident 6's Physician's Orders, the Physician's Orders indicated to give the following medications via GT: - Aspirin (pain reducer medication) 81 mg 1 tablet via GT once a day - Folic Acid (vitamin supplement) 1 mg 1 tablet via GT once a day During a concurrent observation and interview on 11/8/2024 at 9:51 a.m., observed RN 4 provided GT care to Resident 5. Observed that RN 4 inside Resident 5's room wearing gloves and mask. RN 4 accessed Resident 1's GT, removed her gloves and leave the room without performing hand hygiene. Observe RN 4 went to the medication cart and prepared Resident 6's medication. RN 4 stated she must wear gown during GT site care for Resident 5 and perform hand hygiene after removing her gloves and before preparing Resident 6's medication. During an interview on 11/8/2024 at 10:34 a.m., Infection Preventionist (IP) stated RN 4 must wear gown, before handling GT of Resident 5 and perform hand hygiene after removing gloves because RN 4 could transmit microorganism to self and to other residents. During an interview on 11/8/2024 at 11:27 a.m., Director of Nursing (DON) stated RN 4 must wear proper EBP attire before touching the resident to prevent cross contamination to other residents. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions (EBP) 2024, last reviewed date on 1/18/2024, indicated the facility shall establish and infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection.

Based on observation, interview, and record review, the facility failed to provide a homelike environment by failing to ensure resident privacy curtains are free of splash stain for one of eight sampled residents (Resident 97) reviewed under the environment task. This deficient practice had the potential to negatively affect Resident 97's psychosocial wellbeing by feeling uncomfortable in his living space and violated the resident's rights to a safe, clean, and homelike environment. Findings: During a review of Resident 97's admission Record, the admission Record indicated the facility admitted the resident on 12/18/2023 and readmitted the resident on 10/8/2024 with diagnoses including chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), dependence on a ventilator (machine that pumps air into patients' airways when they are unable to adequately breathe on their own), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and end stage renal disease (a medical condition in which a person's kidneys [organs that remove waste products from the blood and produce urine] stop functioning on a permanent basis) During a review of Resident 97's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/26/2024, the MDS indicated the resident was sometimes able to understand others and sometimes able to make himself understood. The MDS indicated the resident was dependent on staff for toileting, dressing, personal hygiene, bathing, oral hygiene, and mobility. During a review of Resident 97's Care Plan (CP) titled, Impaired cognition, impaired communication . initiated 10/10/2024, the CP indicated the resident's needs will be anticipated and met. The CP further indicated to provide soothing auditory and visual stimuli. During an observation on 10/22/2024 at 10:47 a.m., observed Resident 97 lying in bed, awake, and facing the direction of the privacy curtain at the right side of the bed. Observed two large, brown splash stains on the curtain. During a concurrent observation and interview on 10/22/2024 at 10:52 a.m., Licensed Vocation Nurse 1 (LVN 1) entered Resident 97's room and stated the resident was not feeling well. LVN 1 stated there were large dry splash stains on the resident's privacy curtain and they should not be there. LVN 1 stated maintenance should have been notified to change the curtains. During an interview on 10/25/2024 at 10 a.m. with the Infection Preventionist (IP), the IP stated he is not able to say what happened to Resident 97's curtains, but the stains appeared to be a dried body fluid and the curtains should have been changed immediately when they were soiled because the fluid may have contained infectious organisms that could spread when touched. The IP stated having large splash stains on Resident 97's curtains is not a homelike environment and could have potentially affected the resident's mental wellbeing resulting in depression or anxiety at seeing the stains. During an interview on 10/25/2024 at 1:55 p.m. with the Director of Nursing (DON), the DON stated Resident 97's curtains should have been changed when the splash occurred. The DON stated housekeeping, or the nurses, should have noticed the stain and told maintenance to change the curtains. The DON stated this is Resident 97's home and it is not a homelike environment to have dirty curtains. During a review of the facility Policy and Procedure (P&P) titled, Homelike Environment, dated 3/2024, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment. Staff should provide person-centered care that emphasizes the resident's comfort and personal needs. The facility staff and management shall maximize, the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team to meet the individual needs for three of 13 sampled residents (Residents 93, 37, and 15) by failing to: 1. Ensure Resident 93's bedrails/side rails (a board or a rail that runs along the side of a bed, connecting the headboard and footboard) care plan (a written document that outlines the care and support needs of a person) followed Resident 93's physician's order. 2. Ensure Resident 37's bedrails/side rails care plan followed Resident 37's physician's order. 3. Ensure Resident 15's Restorative Nursing Restorative Nursing Assistant program [(RNA), nursing aide program that help residents to maintain their function and joint mobility] care plan reflected Resident 15's current RNA orders. These deficient practices had the potential for inappropriate care and treatment, and minimizes the facility's ability to review the effectiveness of the treatments, decreasing overall quality of life. Findings: 1. During a review of Resident 93's admission Record (AR), the AR indicated the facility admitted the resident on 9/11/2023, and readmitted the resident on 7/9/2024, with diagnoses including spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder that affects all four limbs, trunk, and the face), epilepsy (a chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), and unspecified intracranial injury (a brain injury caused by a head injury, such as a fall or a blow to the head). During a review of Resident 93's Minimum Data Set (MDS), a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on staff for mobility and activities of daily living [(ADLs), routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves)]. During a review of Resident 93's Physician Orders, dated 7/9/2024, indicated an order for side rails up due to safety (informed consent verified with M.D.). During a review of Resident 93's Care Plan (CP) titled Potential for injury: Use of restraints side rails up times (X) 2 when in bed, updated 9/16/2024, indicated a care plan to perform routine check to make sure that the siderails stay up. During a concurrent observation, interview, and record review on 10/24/2024, at 11:10 a.m., with Registered Nurse 7 (RN 7), inside Resident 93's room, observed Resident 93 lying in bed with all 4 side rails/bedrails up. Reviewed Resident 93's Physician Orders and Care Plans. RN 7 stated the resident had an order for side rails up and the care plan only indicated partial or 2 side rails/bedrails up. RN 7 stated the care plan should be accurate and updated as the resident had 4 side rails/bedrails used as a restraint to prevent the resident from falls. RN 7 stated the care for residents with 2 siderail/bedrail and full siderail/bedrail was different as all 4 bedrails are more restrictive and requires more interventions to prevent accidents such as entrapment (when a resident is trapped or caught in a hospital bed, either in or around the bed rails, mattress, or frame). During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), The DON stated it was important to revise and update the care plan to ensure an accurate picture of the resident's health status. The DON stated there was a big difference between the care of a resident with 2 side rails versus 4 siderails and the care plan should be revised and updated accordingly for patient safety. During a review of the facility's recent policy and procedure (P&P) titled, Comprehensive Care Plans, last reviewed on 1/18/2024, the P&P indicated the comprehensive care plans will be reviewed, revised, and completed within seven days after completion of the comprehensive assessment, which is prepared by the interdisciplinary team, that includes but is not limited to- a. A Registered Nurse with responsibility for the resident. b. Dietician c. The Resident and/or Resident's representative to the extent possible d. Respiratory Therapist e. Activities Representative f. Social Services g. Care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 2. During a review of Resident 37's admission Record (AR), the AR indicated the facility admitted the resident on 11/30/2014, and readmitted the resident on 7/19/2018, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), dependence on respirator (a mechanical device that helps a person breathe by moving air into and out of their lungs), and tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs). During a review of Resident 37's MDS , dated 7/22/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The resident required moderate to supervision assistance on mobility and activities of daily living (ADLs). During a review of Resident 37's Bedrail Use and Entrapment Risk Evaluation, dated 1/23/2024, the evaluation indication the resident had balance deficit and had mild developmental delay. During a concurrent observation, interview, and record review on 10/24/2024, at 9 a.m., with Registered Nurse 6 (RN 6), inside Resident 37's room, observed Resident 37 lying in bed with the bedrail/ siderails with all 4 side rails up. Reviewed Resident 37's Physician Orders and Care Plans. RN 6 stated the care plan on file is indicating only 2 side rails up. RN 6 stated the care plan should reflect the actual intervention being rendered to the resident for safety. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), The DON stated it was important to revise and update the care plan to ensure an accurate picture of the resident's health status. The DON stated there was a big difference between the care of a resident with 2 side rails versus 4 siderails. The care plan should be revised and updated accordingly for patient safety. During a review of the facility's recent policy and procedure (P&P) titled, Comprehensive Care Plans, last reviewed on 1/18/2024, the P&P indicated the comprehensive care plans will be reviewed, revised, and completed within seven days after completion of the comprehensive assessment, which is prepared by the interdisciplinary team, that includes but is not limited to- a. A Registered Nurse with responsibility for the resident. b. Dietician c. The Resident and/or Resident's representative to the extent possible d. Respiratory Therapist e. Activities Representative f. Social Services g. Care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 3. During a review of Resident 15's Record of admission indicated, the admission Record Resident 15 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including, but not limited to chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and encephalopathy (any damage or disease that affects the brain). During a review of Resident 15's Annual History and Physical (H&P) dated 8/4/2024, the H&P indicated Resident 15 did not have the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS), - a federally mandated resident assessment tool) dated 10/22/2024, the MDS indicated Resident 15 indicated Resident 15 required dependent assistance from staff for oral hygiene, toileting hygiene, upper and lower body dressing and rolling left and right in bed. The MDS also indicated Resident 15 had functional impairment in range of motion [(ROM), full movement potential of a joint)] on both sides of the upper and lower extremities. During a review of Resident 15's Physician's Orders (PO) dated 8/13/2018, the PO indicated an order dated 8/13/2018 for passive range of motion (PROM, movement at a given joint with full assistance from another person) to all extremities 10 to 15 minutes twice a day by a Restorative Nursing Assistant (RNA - nursing assistant program that help residents to maintain their function and joint mobility) prior to splinting (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and an order dated 8/29/2022 for bilateral (both sides) hand splints twice a day from 0700 to 0800 and from 1300 and 1400 for one hour by RNA while resident is on his back. During a review of Resident 15's care plan dated 8/2024 the care plan indicated concerns and problems were limitations in the functional ROM in the following areas: right (R) hip severe, left (L) hip moderate, R knee severe, L moderate, both ankle severe, both elbow functional range of motion, both wrists functional range of motion, both fingers functional range of motion, shoulder minimum. The care plan indicated the approach plan was for PROM to all extremities once a day by RNA apply both hand splints (no time frame for wearing time was indicated). During an observation on 10/22/2024 at 12:22 p.m., Resident 15 was laying on the back in bed. Resident 15's right elbow was bent about halfway and the right wrist and hand were in a blue splint. Resident 15's left elbow was bent and the left wrist and hand was in a blue splint and rotated away from the body. During a concurrent interview and record review on 10/23/2024 at 1:50 p.m., Registered Nurse supervisor (RN) 1) reviewed Resident 15's care plan dated 8/2024 and Resident 15's RNA orders dated 8/13/2018 and 8/29/2022 and stated Resident 15's care plan for RNA does not match the current and active RNA orders for Resident 15. RN 1 stated the care plan should reflect the RNA treatment for PROM twice a day and indicate Resident 15 should have both hand splints on every day for one hour from 7:00 a.m. to 8:00 a.m. and then for another hour at 1:00 p.m. and 2:00 p.m. RN 1 stated care plans should be revised to reflect the current orders because care plans were aligned with the care that the resident should be receiving based on the order. RN 1 stated a care plan helps staff to ensure the resident received quality care, assists staff to know what to monitor and how to re-assess the resident based on the issue or diagnosis. RN 1 stated it was important to make sure that the care plans were revised and up to date. During an interview on 10/23/2024 at 4:22 p.m., the Director of Nursing (DON), the DON stated the purpose of a care plan was to provide an overview of the resident and what the facility was providing to the resident and for all staff to know what was going on with the resident. The DON stated the care plan should reflect what the resident was receiving and based on the actual physician's order. The DON stated the RNA care plan should reflect the RNA treatment orders. A review of the facility's policy and procedure reviewed 4/2024, titled, Restorative Nursing Services,, indicated restorative goals and objectives are individualized and resident-centered, and are outlined in the residents' plan of care. A review of the facility's policy and procedures revised 3/2024, titled, Comprehensive Care Plans,, indicated the care plans will include minimum healthcare information necessary to properly care for a resident including physician orders. The comprehensive care plans will be reviewed, revised, and completed.

Based on observation, interview, and record review, the facility failed to ensure the resident was provided with showers for one of two sampled residents (Resident 104) investigated under activities of daily living. This deficient practice had the potential for Resident 104 to feel frustrated and embarrassed, due to lack of or delay in receiving sufficient services to maintain good grooming, personal and oral hygiene; and incontinence care and had the potential to lead to skin breakdown, and social isolation. Findings: During a review of Resident 104's admission Record (AR), the AR indicated the facility admitted the resident on 7/3/2024, and readmitted the resident on 8/26/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), dependence on respirator (a mechanical device that helps a patient breathe by moving air into and out of their lungs), and major depressive disorder (a mental health condition that involves a depressed mood and loss of interest in activities for a significant amount of time). During a review of Resident 104's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/14/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 104 was dependent on shower, bathing and was always incontinent of urine and bowel (feces). During an interview on 10/22/2024, at 9:22 a.m., with Resident 104, inside the resident's room, Resident 104 stated the facility seems to not have a regular schedule for showering the residents. Resident 104 stated she had shortness of breath on Sunday (10/20/2024) and was not showered that day, however, on Wednesday (10/16/2024) she should have a shower that day but was skipped. During an interview and record review on 10/24/2024, at 7:58 a.m., with Registered Nurse 2 (RN 2), the facility's Shower Schedule, Certified Nursing Assistant (CNA) Shower List, and the Adult 24-hour Flow Sheet were reviewed. RN 2 stated Resident 104 gets her shower every Wednesdays and Sundays during the evening shift (3 p.m. to 11 p.m.) per the Shower Schedule. RN 2 stated there was no record of Resident 104 having a shower for 10/2024 on the CNA Shower List. RN 2 stated the following reflected on the Adult 24-hour Flow Sheets: - 10/2/2024 (Wednesday) Partial baths at 8 p.m. and 2 a.m. - 10/6/2024 (Sunday) Bed baths at 8 a.m. and at 10 p.m. - 10/9/2024 (Wednesday) Bed bath at 10 a.m. - 10/13/2024 (Sunday) Bed bath at 2 p.m., and partial baths at 12 a.m., 2 a.m., and 6 a.m. - 10/20/2024 (Sunday) Partial baths at 4 p.m., 6 p.m., 12 a.m., 2 a.m., and 6 a.m. - 10/23/2024 (Wednesday) Shower at 4 p.m. RN 2 stated Resident 104 should be showered as scheduled because it is a basic component of health maintenance, and the failure to provide the showers to the resident as scheduled affected the dignity and self-worth of the resident. During an interview on 10/24/2024, at 8:18 a.m., with Licensed Vocational Nurse 9 (LVN 9), LVN 9 stated she had been caring for Resident 104 for a long time and she had not experienced Resident 104 refusing to have a shower. During a review of the facility's Shower Schedule, last updated on 4/30/2024, the schedule indicated Resident 104 will have a shower every Wednesdays and Sundays. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated the staff should stick to the shower schedule of Resident 104 to promote dignity and good hygiene to the resident. The DON stated the facility is the resident's home, so they need to honor the resident's preference of showering to promote comfort and well-being to the resident. During a review of the facility's recent policy and procedure (P&P) titled, Shower Procedures, last reviewed on 1/18/2024, the P&P indicated residents will be given a shower room as scheduled and if needed (PRN).

Based on observation, interview, and record review, the facility failed to ensure the resident's low air loss mattress (LALM, a specialized mattress designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight for one of two sampled residents (Resident 261). This failure had the potential for Resident 261's skin to break down. Findings: During a review of Resident 261's Record of Admission, the record of admission indicated the facility originally admitted the resident on 12/21/2011, and readmitted the resident on 10/15/2024 with diagnoses including, but not limited to, quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 261's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/15/2024, the MDS indicated Resident 261 was rarely or never understood, had impairment on both upper and lower extremities, was dependent on facility staff for activities of daily living including hygiene, dressing, toileting, and surface-to-surface transfers, was at risk for developing pressure ulcers, and used a pressure reducing device on her bed. During a review of Resident 261's Care Plan, dated 10/22/2024, the care plan indicated a concern related to actual and potential alteration in skin integrity with approaches including, but not limited to, check LALM pressure every shift and set per resident's weight for skin management. During a review of Resident 261's Weight Record, dated 10/15/2024, the weight record indicated Resident 261 weighed 34.4 kilograms (a unit of measure for mass), which is equal to 75.84 pounds. During an observation on 10/22/2024, at 10:00 a.m., inside Resident 261's room, Resident 261 was lying in bed, facing towards her left side. Resident 261's bed had a LALM controller hanging on the foot of the bed. The LALM controller were set to static, low pressure, 320 pounds. During an interview on 10/22/2024 at 4:45 p.m., with the Director of Nursing (DON), the DON stated LALM should be set to the resident's weight to prevent skin breakdown. The DON further stated if the LALM is not set correctly, there is potential to place the resident at risk for skin breakdown. During a review of the facility's policy and procedure (P&P) titled, Low Air Loss Mattress, last reviewed 3/2024, the P&P indicated LALM will be used for residents who have actual or potential for pressure ulcers. During a review of the facility provided document titled, [LALM Manufacturer 1] Operating Manual, undated, the document indicated the pressure adjustment knob controls the air pressure in the mattress. The document indicated turning the knob clockwise will increase the pressure and turning it counterclockwise decreases the pressure. The document indicated higher pressures will support heavier residents. The document further indicated the alternate/static switch selects between alternate pressure mode and static pressure mode, with alternate pressure mode alternating air cells are partially deflated and inflated, avoiding prolonged pressure on any single point beneath the resident to prevent pressure ulcers.

Based on observation, interview, and record review, the facility failed to ensure Respiratory Therapist 1 (RT 1) provided tracheostomy (opening surgically created through the front of the neck and into the windpipe) care per the physician's orders by cleaning the resident's stoma (a surgically created hole) with water and rinsing with normal saline (NS, a sterile solution) for one of four sampled residents (Resident 15). This deficient practice placed Resident 15 at risk for respiratory distress and infection. Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility admitted the resident on 12/1/2006 and most recently readmitted the resident on 8/13/2010 with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheostomy, sepsis (a life-threatening blood infection), and pneumonia (an infection/inflammation in the lungs). During a review of Resident 15's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/22/2024, the Minimum Data Set indicated the resident was in a persistent vegetative state (a chronic condition where a person appears to be awake but shows no awareness of their surroundings) / no discernible consciousness. The MDS further indicated the resident was dependent on staff for toileting, dressing, personal hygiene, bathing, oral hygiene, and mobility. During a review of Resident 15's Physician's Orders, the physician's orders indicated the following order: - Tracheostomy care every shift and as needed: cleanse the stoma with water and rinse with NS, change the trach tie every shift, dressing change, dated 2/3/2023. During a review of Resident 15's Care Plan (CP) titled, Presence of tracheostomy: ineffective airway clearance related to inability to expel excess secretions, ., potential for infection, initiated 8/12/2024, the CP indicated the resident would achieve a patent airway at all times and would be free from signs and symptoms of infection. The CP further indicated to provide trach care every shift. During an observation on 10/24/2024 at 1:55 p.m., RT 1 provided tracheostomy care to Resident 15. Observed RT 1 use dry gauze to wipe Resident 15's stoma. Observed RT 1 did not use water or NS during tracheostomy care. During an interview and record review on 10/24/2024 at 2:20 p.m., with RT 1, Resident 15's physician order for tracheostomy care, dated 2/3/2023 was reviewed. RT 1 stated he did not cleanse Resident 15's stoma with water and rinse with NS. RT 1 stated moistening the gauze loosens the dry secretions and cleans away any buildup at the stoma that may cause an infection. RT 1 stated he should have moistened Resident 15's gauze with water, cleansed around the stoma, and then rinsed with NS; but he didn't. RT 1 stated he did not moisten the gauze because he was nervous and forgot. During an interview on 10/25/2024 at 10 a.m. with the Infection Preventionist (IP), the IP stated dry gauze is rough and cannot adequately remove dry secretions around a tracheostomy stoma. The IP stated the purpose of removing dry secretions is to prevent the secretions from reducing the diameter of the tracheostomy opening and potentially causing desaturation (amount of oxygen the blood is carrying to the body) issues. The IP stated when secretions are not removed, they can also grow bacteria potentially leading to a respiratory infection. During a review of the facility policy and procedure titled, Tracheostomy Care / Routine Daily Care / Inner Cannula [a hard disposable plastic tube] Care, last reviewed 1/18/2024, indicated tracheostomies will be kept clean and the airway clear of mucus. Tracheostomy care will be done daily and as needed. The purpose is to maintain an adequate airway and to clear excessive secretions, to prevent encrustation of the tracheostomy tube inner cannula, to prevent breakdown or irritation of the surrounding skin, and to maintain patency of the tracheostomy. Clean around the stoma with NS moist gauze, then clean around the neck with NS moist gauze.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to keep the pad call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach for four of six sampled residents (Resident 463, 75, 18, and 4) reviewed during investigation of the environment facility task. This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being. a. During a review of Resident 463's admission Record (AR), the AR indicated the facility admitted the resident on 10/1/2024, with diagnoses including tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and nontraumatic intracranial hemorrhage (bleeding in the brain that occurs without trauma or surgery). During a review of Resident 463's History and Physical (H&P), dated 10/2/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 463's Minimum Data Set (MDS), a federally mandated resident assessment tool), dated 10/13/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on staff for mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 463's Bedrail Use and Entrapment Risk Evaluation, dated 10/2/2024, the evaluation indicated the resident had balance deficit and was unable to support trunk (the central part of the body that connects the head, arms, and legs). During a concurrent observation and interview on 10/22/2024, at 10:14 a.m., with the Director of Staff Development (DSD), observed Resident 463's pad call light not within the reach of the resident. The pad call light was placed on top of the ventilator (a device for maintaining artificial respiration). The DSD stated the pad call light should be within the reach of the resident so the resident can call for help when needed. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated the pad call light should be within reach of the resident to call for help during emergency. The DON stated the failure of the staff to keep the pad call light within reach can result in the resident not being able to call for help and can potentially fall while reaching for the pad call light. During a review of the facility's recent policy and procedure (P&P) titled Call Lights, last reviewed on 1/18/2024, the P&P indicated the call light will be placed within their reach. b. During a review of Resident 75's admission Record (AR), the AR indicated the facility admitted the resident on 4/29/2022 with diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the windpipe to facilitate breathing), and spastic quadriplegia cerebral palsy (loss of function of both arms and legs with muscle stiffness due to injury to the brain from a young age). During a review of Resident 75's History and Physical (H&P) dated 4/22/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 75's Minimum Data Set (MDS), a federally mandated resident assessment tool), dated 10/10/2024, the MDS indicated Resident 75 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living [(ADLs) - basic tasks that must be accomplished every day for an individual to thrive)]. The MDS indicated Resident 75 had impairment of both upper and lower extremities. During a review of Resident 75's fall risk assessment dated [DATE], the assessment indicated the resident was a high risk for falls. During a review of Resident 75's care plan (CP) on potential for falls and injury related to spastic quadriplegia cerebral palsy last updated 5/10/2024, the CP indicated to always place call light within reach as one of the interventions to free resident from falls and injury. During a concurrent observation and interview on 10/22/2024 at 9:55 a.m. inside Resident 75's room, with Licensed Vocational Nurse 5 (LVN 5), observed Resident 75's call light on top of the pulse oximeter machine (a small, electronic device clipped onto a fingertip or earlobe that measures the amount of oxygen in the blood). LVN 5 stated the call light is called an adaptive call light (a type of call light system that have ultra-sensitive touch surfaces ideal for patients with limited movement of both arms/hands). LVN 5 verified the call light was placed on top of the pulse oximeter machine and not within Resident 75's reach. LVN 5 stated the call light should have been within reach close to the resident's cheek area so the resident can call for assistance when needed. During a concurrent interview and record review on 10/25/2024 at 1:55 p.m., reviewed the facility's policy and procedure (P&P) titled, Call Light, with the DON. The DON stated she was made aware of the call light not within Resident 75's reach. The DON verified the staff did not follow the facility P&P placing the call light within the resident's reach. The DON stated the staff were supposed to place the call light within resident reach after providing care to the resident and monitor placement to ensure the resident will be able to ask for assistance when needed to prevent delay in the delivery of care. During a review of the facility's P&P titled, Call Light, last reviewed 1/18/2024, the P&P indicated a purpose to enable patients/residents to call for assistance and to enable all staff to respond to call lights in a timely and efficient manner. The P&P indicated the following: - The call light will be placed within reach. - Call lights will be monitored for positioning by Licensed Nurses and Certified Nursing Assistants during rounds and after treatments. c. During a review of Resident 18's admission Record, the AR indicated the facility admitted the resident on 12/6/2007 and readmitted in the facility 11/2/2023 w ith diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the windpipe to facilitate breathing), and spastic quadriplegia cerebral palsy (loss of function of both arms and legs with muscle stiffness due to injury to the brain from a young age). During a review of Resident 18's History and Physical (H&P), dated 11/3/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 18's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/9/2024, the MDS indicated Resident 18 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 18 had impairment of both upper and lower extremities. During a review of Resident 18's fall risk assessment dated [DATE], the assessment indicated resident was a high risk for falls. During a review of Resident 18's care plan (CP) on potential for falls and injury related to spastic quadriplegia cerebral palsy last updated 10/15/2024, the CP indicated to always place call light within reach as one of the interventions to free resident from falls and injury. During a concurrent observation and interview on 10/22/2024 at 10:29 a.m. inside Resident 18's room with Licensed Vocational Nurse 12 (LVN 12), observed Resident 18's call light hanging on the left side of the bed between the mattress and the left upper siderail. LVN 12 stated staff were supposed to place call light within reach after providing care to the resident. LVN 12 verified Resident 18's call light was not within reach and stated the call light should have been within reach so the resident can ask for assistance when needed. During a concurrent interview and record review on 10/25/2024 at 1:55 p.m., reviewed the facility's policy and procedure (P&P) titled, Call Light, with the DON. The DON stated she was made aware of the call light not within Resident 75's reach. The DON verified the staff did not follow the facility P&P that the call light will be placed within the resident's reach. The DON stated the staff were supposed to place the call light within resident reach after providing care to the resident and monitor placement to ensure the resident will be able to ask for assistance when needed to prevent delay in the delivery of care. During a review of the facility's P&P titled, Call Light, last reviewed 1/18/2024, the P&P indicated a purpose to enable patients/residents to call for assistance and to enable all staff to respond to call lights in a timely and efficient manner. The P&P indicated the following: - The call light will be placed within reach. - Call lights will be monitored for positioning by Licensed Nurses and Certified Nursing Assistants during rounds and after treatments. d. During a review of Resident 4's Record of admission (RA), the RA indicated the facility originally admitted the resident on 10/10/2017 and readmitted on [DATE], with diagnoses including cerebral palsy (a group of conditions that affect movement and posture) and gastrostomy. During a review of Resident 4's Annual History and Physical (H&P), dated 4/12/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS), -a federally mandated resident assessment tool), dated 9/19/2024, the MDS indicated the resident rarely had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on staff for activities of daily living [(ADLs)- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves)]. During a review of Resident 4's Risk for Falls (RF), dated 4/12/2024, the RF indicated the resident at risk for falls. During a review of Resident 4's Care Plan (CP) addressing potential for falling, last re-evaluated on 10/2024, the CP indicated the resident had goals to be free from falls and injury with interventions including placing call light within reach. During an observation on 10/22/2024 at 9:19 a.m., inside Resident 4's room, observed Resident 4's call light sitting on the floor outside the resident's bed frame enclosure (a hospital bed with a canopy and mattress to prevent patient from getting out of bed unassisted). During a concurrent observation and interview on 10/22/2024 at 9:28 a.m., Certified Nurse Assistant (CNA) 1 stated Resident 4's call light button was on the floor and should be within reach so Resident 4 can call for help in case of emergency or when he needs the call light. During an interview on 10/22/2024 at 4:43 p.m., the DON stated the purpose of the call light is to take care of the resident's needs right away and in case of emergency they can use so facility staff can come in and assist them. The DON stated when the call light was not within reach there will be a delay in meeting the resident's needs. The DON stated the call light should be within reach inside the resident's bed frame enclosure. During a review of the facility's P&P titled Call Lights, last reviewed on 1/18/2024, the P&P indicated the call light will be placed within their reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observations, the facility failed to maintain resident protected health information ([PHI] - any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) by not shredding or covering pharmacy medication labels (a label that includes the residents name, date of birth , name of pharmacy, name of medication, dose, its indication and instructions of use) containing resident medical information on medication bubble packs (medication packaging system that contains individual doses of medication per bubble) prior to disposing in the waste container, affecting two (2) residents (Resident 69 and 80) in one of one inspected biohazard (any biological or chemical substance that is dangerous to humans, animals, or the environment) room. As a result, the privacy and confidentially of Resident 69's and 80's medical records were not securely maintained. Findings: During an observation on 10/22/24 at 2:10 p.m., with the Director of Nursing (DON) in the biohazard room, there was a black plastic waste container with a white lid that contained wasted medications wrapped in clear plastic bags. The bag contained two (2) medication bubble packs for Resident 69 and 80 with the pharmacy label intact and visible through the bag. During a concurrent interview with DON, the DON stated a third-party (an outside contracted entity not part of the facility) vendor (an individual or company that sells goods or services to someone else) usually picks up the black containers once a month to dispose (discard) of the wasted medications. The DON stated the pharmacy labels in the medication bubble packs, containing resident medical information needed to be removed, shredded or covered by an Identi-Hide (a permanent, opaque white label that covers patient information on a container or bag to ensure Health Insurance Portability and Accountability Act [HIPPA - a federal law that protects the privacy and security of health information compliance]) prior to placing them in waste containers to maintain resident confidentiality. The DON stated the facility failed to protect Resident 69's and 80's privacy by failing to cover two (2) pharmacy labels on the medication bubble packs wrapped in clear plastic bags inside the black plastic waste container visibly exposing the residents' PHI. During an interview on 10/22/24 at 4:05 p.m., with Registered Nurse (RN) 3, RN 3 stated that medications in the waste containers should not contain resident health information and should be covered with a label or marked with a sharpie. RN 3 stated the process of covering or removing resident information from the medication bubble packs prior to placing them in the waste containers was not done consistently, and this failure was considered a HIPPA violation as resident health information was visibly exposed to vendors. During an interview on 10/23/24 at 3:05 p.m , with the Director of Staff Development (DSD,) the DSD stated that she (DSD) is responsible for teaching staff upon hire and annually on HIPPA guidelines which included maintaining resident privacy of PHI such as, resident name, date of birth , diagnosis, medication information. The DSD stated that according to the lesson plan and a quiz used in teaching staff about HIPPA, PHI should be shredded or covered prior to trashing. The DSD stated medication bubble packs containing resident health information should be shredded or covered to not exposed PHI to outside vendors. The DSD stated that staff were aware of the process of wasting medications according to HIPPA guidelines and failed to do so consistently. During an interview on 10/23/24 at 3:39 p.m., with the Consultant Pharmacist (CP,) the CP stated that resident medication labels contain PHI and should be shredded and not thrown in the waste bin intact to protect resident privacy and health information. During a review of the policy and procedures (P&P), titled Health Insurance Portability and Accountability Act (HIPAA), dated 1/15/23, the P&P indicated The Purpose of this policy is to educate All Saints HealthCare employees about HIPPA laws and their practical application in a health care facility. 1. All Employees will be educated about resident's rights under HIPAA federal law upon hire, annually, and as needed. 2. HIPAA education will cover all aspects of the law: D. What is protected health information (PHI)? H. What are the resident's privacy rights? I. What must we do to comply? J. What are our policy and procedures? K. What are our security standards? M. What can you do to protect resident's rights? 3. A HIPAA quiz may be given after educating staff upon hire, annually, and as needed to ascertain employee understanding of the law. Some practical applications of HIPPA! 3. Resident's medication or personal information may not be shared with employees who are not assigned to the resident. 7. Scarp sheet of paper with resident information on them .must be shredded after use, not thrown in the garbage. HIPAA QUIZ 1. The HIPPA Privacy Rule Protects a resident's fundamental right to privacy and confidentiality. True or False 2. PHI is anything that connects a resident to his or her health information. True or False 4. It is not necessary to shred papers containing PHI, if you throw them in facility trash can. True or False [NAME] a review of the facility In-Service Lesson plan, titled Staff will understand resident's rights as provided under HIPAA federal law, dated 4/2/24, the lesson plan indicated: 3. What is Protected Health Information? PHI includes any information oral, recorded, on paper, electronic, about a person's physical or mental health, services rendered, payments for the services, and any information that connects the resident to their health care information. Names, address, Birth Date, account numbers, email etc. 5. The rules for use and discloser of PHI is as follows: d. How do you discard or destroy PHI? Shred only .SHRED DON'T TRASH!!

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 45's admission Record indicated the facility admitted the resident on 5/17/2024 and was readmitted on [DATE] with diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into windpipe to facilitate breathing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 45's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 45's Minimum Data Set (MDS), a federally mandated resident assessment tool), dated 9/5/2024, the MDS indicated Resident 45 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living [(ADLs) - basic tasks that must be accomplished every day for an individual to thrive)]. The MDS indicated the resident had impairment on both upper and lower extremities. During a review of Resident 45's Physician Orders, the Physician Orders dated 9/20/2024 indicated, - Apply hand mittens to right hand to prevent pulling life sustaining tube and scratching, may remove mitten when responsible party is at bedside. Remove mitten every two hours for skin assessment. During a concurrent observation and interview on 10/22/2024 at 12:30 p.m., inside Resident 45's room with Registered Nurse 4 (RN) 4), RN 4 observed the resident had a hand mitten on the right hand. RN 4 stated the mitten was to prevent the resident from pulling out tubes due to resident moving frequently while in the bed. During a concurrent interview and record review on 10/25/2024 at 9:23 a.m., reviewed Resident 45's physician's orders, care plans, informed consents, fall risk assessment, restraint assessment, and bedrail and entrapment risk evaluation with the Minimum Data Set Coordinator (MDSC). The MDSC stated facility practice regarding completion of assessments such as bedrail use and entrapment risk evaluation and restraint assessments were completed upon admission, readmission, and annually. The MDSC verified there was no quarterly assessments for the continued use of right-hand mitten. The MDSC stated the restraint assessment should have been completed quarterly per facility policy to ensure continued use of the right-hand mitten remained appropriate and safe. During a review of the facility's P&P titled, Protective Devices and Restraints, last reviewed on 1/18/2024, the P&P indicated the following: with rare exception, a physician's authorization is required initially for their use. When protective devices or restraints are used, the staff should make observations and take precautions to attempt to prevent problems and complications related to their use. The physician's order will contain the specific type of protective device(s) to be used (for example, wrist restraints, pelvic device, waist device, or padded mittens). Also, the physician's orders or progress notes should reflect the reason for ordering the device(s). Periodically, the attending physician and nursing staff will consider whether an individual still needs the device(s), or if their use could be reduced or eliminated. During a review of the facility's P&P titled, Informed Consent for General Care, last reviewed on 1/18/2024, the P&P indicated the physician, family nurse practitioner, or registered nurse will explain the following information to the resident/responsible party: A. Reason for treatment and nature of illness. B. Nature of procedures to be used in treatment including probable/possible duration, C. Possible/probable degree and duration of improvement. D. Reasonable alternative treatment and risks. Reason for proposed treatment. Based on observation, interview, and record review the facility failed to ensure residents were free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for six of six sampled residents (Residents 80, 19, 461, 37, 71, and 45) by failing to: 1. Perform a Bedrail/side rail (a safety device that can be installed on the side of a bed to help people get in and out of bed, turn in bed, and prevent falls) Use and Entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame) Risk Evaluation quarterly for Residents 80, 19, 461, and 71. 2. Obtain a physician's order on the use of restraint bed placed against the wall, assess the need for the restraint and evaluate for bed entrapment, obtain an informed consent, and explain the risk and benefits to the resident/resident representative on the use of restraint bed placed against the wall, and develop and implement a care plan on the use of restraint bed placed against the wall for Resident 37. 3. Complete the initial and quarterly restraint assessment and obtain written or signed informed consent from the resident or resident representative prior to use of left-hand mitten (a type of glove that covers patient hand to prevent from pulling out any essential line or tubes) for Resident 71 and complete the initial and quarterly restraint assessment for the use of right-hand mitten for Resident 45. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents. Findings: 1.a. During a review of Resident 80's admission Record (AR), the AR indicated the facility admitted the resident on 3/20/2024, and was readmitted on [DATE], with diagnoses including anxiety disorder (a mental health condition that causes a person to experience excessive and persistent feelings of fear, dread, and uneasiness) and convulsions (a condition where a person's muscles contract and relax rapidly and uncontrollably, causing a shaking and limb movement). During a review of Resident 80's History and Physical (H&P), dated 7/12/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review Resident 80's Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 10/17/2024, the MDS indicated the resident had impaired upper and lower extremities. The MDS also indicated the resident was dependent on staff for mobility and activities of daily living [(ADLs)routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves]. During a review of Resident 80's Physician's Orders (PO), dated 7/12/2024, the PO indicated side rails to be kept up due to seizure disorder (a brain condition that causes a person to have repeated seizures). During a review of Resident 80's Bedrail Use and Entrapment Risk Evaluation, dated 7/12/2024, the evaluation indicated the bedrails were being considered for safety, and the resident had balance deficit, was unable to support trunk (body), and was non-verbal. During a concurrent interview and record review on 10/24/2024, at 9:27 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated the facility does the Bedrail Use and Entrapment Risk Evaluation on admission of the resident to the facility and they do the quarterly evaluation on the restraint quarterly assessment form. The MDSC stated the restraint quarterly assessment form was not sufficient enough to capture the necessary assessments needed for the safe use of bedrails. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated the bedrails should have been assessed quarterly to ensure safe and appropriate use of the bedrails to prevent accidents such as entrapment. 1.b. During a review of Resident 19's AR, the AR indicated the facility admitted the resident on 1/2/2019, and was readmitted on [DATE], with diagnoses including spastic quadriplegic cerebral palsy (a form of cerebral palsy that affects both arms and legs and often the torso and face), encephalopathy (damage or disease that affects the brain), and epilepsy (a brain condition that causes recurring seizures). During a review of Resident 19's H&P, dated 4/16/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident has impaired upper and lower extremities . The MDS also indicated the resident was dependent on staff for mobility and activities of daily living (ADLs). During a review of Resident 19's Physician Orders (PO), dated 4/20/2020, the PO indicated an order for side rails to be kept up due to seizure disorder. During a review of Resident 19's Bedrail Use and Entrapment Risk Evaluation, dated 4/16/2024, the evaluation indicated the bedrails were being considered for safety, and the resident had balance deficit, unable to support trunk (body), and had poor cognition. During a concurrent interview and record review on 10/24/2024, at 9:27 a.m., with the MDSC, the MDSC stated they only do the Bedrail Use and Entrapment Risk Evaluation on admission and the facility does the quarterly assessment on the restraint quarterly assessment form. The MDSC stated the restraint quarterly assessment form was not sufficient enough to capture the necessary assessments needed for safe use of bedrails. During an observation and interview on 10/24/2024, at 4:14 p.m., with Registered Nurse 6 (RN) 6), observed Resident 19 in bed with all four 4 side rails up. RN 6 stated all 4 side rails were up for resident safety. During an interview on 10/25/2024, at 1:55 p.m., with the DON, the DON stated the bedrails should be assessed quarterly to ensure safe and appropriate use of the bedrails to prevent accidents such as entrapment. 1.c. During a review of Resident 461's AR, the AR indicated the facility admitted the resident on 11/12/2020, with diagnoses including anoxic brain damage (occurs when the brain is deprived of oxygen, which can lead to brain cell death), convulsions, and persistent vegetative state (a chronic condition where a person appears to be awake but is unaware of their surroundings or higher mental activity). During a review of Resident 461's H&P, dated 1/16/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 461's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired vision. The MDS also indicated the resident was dependent on staff for mobility and activities of daily living (ADLs). During a review of Resident 461's Physician Orders (PO), dated 11/12/2020, the PO indicated an order of side rails up due to seizure disorder. During a review of Resident 461's Bedrail Use and Entrapment Risk Evaluation, dated 11/24/2023, the evaluation indicated the bedrails were being considered per resident representative request and seizure disorder, and the resident had balance deficit and unable to support trunk. During a concurrent interview and record review on 10/24/2024, at 9:27 a.m., with the MDSC, the MDSC stated they only do the Bedrail Use and Entrapment Risk Evaluation on admission and they do the quarterlies on the restraint quarterly assessment form. The MDSC stated the restraint quarterly assessment form was not sufficient enough to capture the necessary assessments needed for safe use of bedrails. During an interview on 10/25/2024, at 1:55 p.m., with the DON, the DON stated the bedrails should be assessed quarterly to ensure safe and appropriate use of the bedrails to prevent accidents such as entrapment. 1.d. During a review of Resident 71's admission Record indicated the facility admitted the resident on 8/4/2021 and was on 8/6/2022 with diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe] to facilitate breathing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 71's H&P dated 8/2/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 71's MDS), dated [DATE], the MDS indicated Resident 18 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living [(ADLs) - basic tasks that must be accomplished every day for an individual to thrive)]. The MDS indicated the resident had impairment of both upper and both lower extremities. During a review of Resident 71's Physician Orders, the Physician Orders indicated the following: - 8/6/2022: May apply hand mitten to left hand to prevent from pulling life sustaining tubing remove every 2 hours for skin check. - Siderails up due to seizure disorder [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] (informed consent obtained verified with physician) During a review of Resident 71's bedrail use, and entrapment risk evaluation dated 8/9/2024, the evaluation indicated the use of full rails for safety due to balance deficit and resident unable to support trunk (body) to avoid rolling out of bed. During a review of resident 71's restraint assessment dated [DATE], the assessment indicated a to keep siderails up for safety due to poor balance and poor cognition. During a review of Resident 71's fall risk assessment dated [DATE], the assessment indicated the resident was a high risk for falls. During an observation on 10/22/2024 at 10:41 a.m., inside Resident 71's room with Licensed Vocational Nurse 5 (LVN) 5), observed Resident 71 with left-hand mitten on. LVN 5 verified Resident 71 had a left-hand mitten on for safety to prevent the resident from pulling out tubes. During a concurrent interview and record review on 10/25/2024 at 9:23 a.m., reviewed Resident 71's physician's orders, care plans, informed consents, fall risk assessment, restraint assessment, and bedrail and entrapment risk evaluation with the Minimum Data Set Coordinator (MDSC). The MDSC stated, for any restraint or siderail use orders, informed consent should be obtained prior to use of the restraint or siderails. The MDSC stated the facility practice regarding bedrail use and entrapment risk evaluation and restraint assessments were completed upon admission, readmission, and annually. The MDSC verified there was no documented evidence in Resident 71's medical record that an informed consent was obtained from the resident or resident representative prior to use of left-hand mitten to ensure the family was aware of the plan of care as well as the risks and consequences of the restraint. The MDSC verified there was no quarterly assessment for the continued use of left-hand mitten, and bed rail and entrapment risk evaluation. The MDSC stated the restraints assessments and bed rail, and entrapment risk evaluation should have been completed quarterly per facility policy to ensure continued use of the siderail and restraints were appropriate and safe. During a review of the facility's recent policy and procedure (P&P) titled Bed and Crib Rails, last reviewed on 1/18/2024, the P&P indicated bedrail/Restraint use will be evaluated upon admission and quarterly. During a review of the facility's recent policy and procedure (P&P) titled Protective Devices and Restraints, last reviewed on 1/18/2024, the P&P indicated with rare exception, a physician's authorization is required initially for their use. When protective devices or restraints are used, the staff should make observations and take precautions to attempt to prevent problems and complications related to their use. The physician's order will contain the specific type of protective device(s) to be used (for example, wrist restraints, pelvic device, waist device, or padded mittens). Also, the physician's orders or progress notes should reflect the reason for ordering the device(s). Periodically, the attending physician and nursing staff will consider whether an individual still needs the device(s), or if their use could be reduced or eliminated. 2. During a review of Resident 37's admission Record (AR), the AR indicated the facility admitted the resident on 11/30/2014, and was readmitted on [DATE], with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), dependence on respirator (a mechanical device that helps a patient breathe by moving air into and out of their lungs), and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). During a review of Resident 37's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required partial to requiring supervision assistance on mobility and activities of daily living (ADLs). During a review of Resident 37's Physician's Orders (PO), dated 7/19/2018, the PO indicated an order for side rails up and postural support due to decrease cognitive level. The PO did not indicate an order for placing the bed against the wall. During a concurrent observation, interview, and record review on 10/24/2024, at 9:00 a.m., with Registered Nurse 6 (RN) 6), inside Resident 37's room, observed resident lying on bed sleeping with the bed pushed against the wall on the left side of the resident's bed with all four side rails up. Reviewed Resident 37's Physician's Orders, Assessments, Consents, and Care Plans. RN 6 stated before they apply restraints to the residents they should assess the resident on the safety of the use of the restraint, they obtain a physician's order and a consent from the resident or resident representative and develop and implement a care plan on the use of restraint. RN 6 stated placing the resident's bed against the wall was a form of a restraint. RN 6 stated he cannot find the order for bed placed against the wall, the assessment on its safety of use, and no consent from the resident nor the resident representative, and care plan on the use of bed placed against the wall on the resident's medical chart. RN 6 stated their failure to perform all the necessary steps mentioned above placed the resident at risk for injury such as entrapment. During an interview on 10/25/2024, at 1:55 p.m., with the DON, the DON stated there should be an order, assessment on the safe use of the restraint, the staff should have explained the risk and benefits to resident/representative of the use of the restraint, an informed consent, and a care plan on the use of bed placed against the wall before applying them to the resident. During a review of the facility's recent P&P titled Protective Devices and Restraints, last reviewed on 1/18/2024, the P&P indicated, with rare exception, a physician's authorization is required initially for their use. When protective devices or restraints are used, the staff should make observations and take precautions to attempt to prevent problems and complications related to their use. The physician's order will contain the specific type of protective device(s) to be used (for example, wrist restraints, pelvic device, waist device, or padded mittens). Also, the physician's orders or progress notes should reflect the reason for ordering the device(s). Periodically, the attending physician and nursing staff will consider whether an individual still needs the device(s), or if their use could be reduced or eliminated. During a review of the facility's P&P titled, Informed Consent for General Care, last reviewed on 1/18/2024, the P&P indicated the physician, family nurse practitioner, or registered nurse will explain the following information to the resident/responsible party: A. Reason for treatment and nature of illness. B. Nature of procedures to be used in treatment including probable/possible duration, C. Possible/probable degree and duration of improvement. D. Reasonable alternative treatment and risks. Reason for proposed treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 37's admission Record (AR), the AR indicated the facility admitted the resident on 11/30/2014, and readmitted the resident on 7/19/2018, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), dependence on respirator (a mechanical device that helps a patient breathe by moving air into and out of their lungs), and tracheostomy (an opening surgically created through the neck into trachea [windpipe] to allow air to fill the lungs). During a review of Resident 37's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/22/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required moderate to supervision assistance on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 37's Bedrail Use and Entrapment Risk Evaluation, dated 1/23/2024, the evaluation indicated the resident had balance deficit and had mild developmental delay. During a concurrent observation and interview, and record review on 10/24/2024, at 9 a.m., with Registered Nurse 6 (RN 6), inside Resident 37's room, observed Resident 37's left side of the bed placed against the wall. During review of Resident 37's physician's orders and care plans, RN 6 stated placing the resident's bed placed against the wall is considered a restraint because the resident is restricted from getting out from the left side of the bed. RN 6 stated there was no care plan in place for placement of the resident's bed against the wall. RN 6 stated it is important to have a care plan on placement of bed against the wall for resident safety. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated it is important to have a care plan to ensure appropriate care and interventions are provided to the residents. The DON stated the care plan serves as a communication tool to all the healthcare providers and serves as a basis for evaluating the effectiveness of the care provided by the healthcare team. During a review of the facility's recent policy and procedure (P&P) titled, Comprehensive Care Plans, last reviewed on 1/18/2024, the P&P indicated the comprehensive care plans will be reviewed, revised, and completed within seven days after completion of the comprehensive assessment, which is prepared by the interdisciplinary team, that includes but is not limited to- a. A Registered Nurse with responsibility for the resident. b. Dietician c. The Resident and/or Resident's representative to the extent possible d. Respiratory Therapist e. Activities Representative f. Social Services g. Care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. c. During a review of Resident 463's admission Record (AR), the AR indicated the facility admitted the resident on 10/1/2024, with diagnoses including tracheostomy, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and nontraumatic intracranial hemorrhage (bleeding in the brain that occurs without trauma or surgery). During a review of Resident 463's History and Physical (H&P), dated 10/2/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 463's Physician's Order (PO), dated 10/1/2024, the PO indicated an order for side rails up due to safety (informed consent verified with M.D.). During a review of Resident 463's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had severe cognitive impairment (a significant loss of intellectual capacity that makes it difficult for a person to function independently) and was dependent on mobility and activities of daily living (ADLs). During a review of Resident 463's Bedrail Use and Entrapment Risk Evaluation, dated 10/2/2024, the evaluation indicated the bed rails are being considered for safety and the resident had balance deficit and unable to support trunk. During a concurrent interview and record review on 10/24/2024, at 3:04 p.m., with Registered Nurse 2 (RN 2), reviewed Resident 463's Physician's Orders and Care Plans. RN 2 stated there is no care plan developed and implemented on the use of bedrails on the resident. RN 2 stated it is important to have a care plan on the use of bedrails to ensure its safe use and to prevent the resident from accidents such as entrapment. During a concurrent observation and interview on 10/24/2024, at 3:09 p.m., with Registered Nurse 5 (RN 5), inside Resident 463's room, observed the resident's all four side rails/ bed rails in raised position. RN 5 stated the bed rails are applied for resident safety. During an interview on 10/25/2024, at 1:55 p.m., with the DON, the DON stated it is important to have a care plan to ensure appropriate care and interventions are provided to the residents. The DON stated the care plan serves as a communication tool to all the healthcare providers and serves as a basis for evaluating the effectiveness of the care provided by the healthcare team. During a review of the facility's recent policy and procedure (P&P) titled, Comprehensive Care Plans, last reviewed on 1/18/2024, the P&P indicated the comprehensive care plans will be reviewed, revised, and completed within seven days after completion of the comprehensive assessment, which is prepared by the interdisciplinary team, that includes but is not limited to- a. A Registered Nurse with responsibility for the resident. b. Dietician c. The Resident and/or Resident's representative to the extent possible d. Respiratory Therapist e. Activities Representative f. Social Services g. Care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Based on interview and record review the facility failed to develop and implement a comprehensive care plan for three of five sampled residents (Residents 45, 37 and 463) investigated under physical restraints (device or manual holds that limit a person's movement or access to their body) by: 1. Failing to develop and implement a care plan for Resident 45's use of right-hand mitten (a type of glove that covers patient hand to prevent from pulling out any essential line or tubes). 2. Failing to develop and implement a care plan addressing placement of Resident 37's bed against the wall. 3. Failing to develop and implement a care plan addressing use of full side rails (horizontal bars attached to the side of a bed to help prevent falls and provide a sense of security) for Resident 463. These deficient practices had the potential for a delay in care and services of residents. Findings: a. During a review of Resident 45's admission Record, the admission Record indicated the facility admitted the resident on 5/17/2024 and readmitted the resident on 8/25/2024 with diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe] to facilitate breathing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 45's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 45's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/5/2024, the MDS indicated Resident 45 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 45's Physician Orders, the Physician Orders indicated the following: - 9/30/2024: Apply hand mittens to right hand to prevent pulling life sustaining tube and scratching, may remove mitten when responsible party is at bedside. Remove mitten every two hours for skin assessment. During a concurrent observation and interview on 10/22/2024 at 12:30 p.m., inside Resident 45's room with Registered Nurse 4 (RN 4), RN 4 stated the resident is wearing a right hand mitten to prevent the resident from pulling out tubes because the resident moves frequently in bed. During a concurrent interview and record review on 10/25/2024 at 12;22 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 45's physician's order, restraint assessments, informed consents, and care plans. The MDSC stated Resident 45 has a physician order for the application of right-hand mitten to prevent from pulling out life sustaining tubes and scratching. The MDSC stated there was no care plan developed and implemented addressing the use of right-hand mitten. The MDSC stated a care plan should have been created as soon as the order for use of right hand mitten was received from the physician to ensure staff are aware of the resident's plan of care and to prevent a delay in providing care to the resident. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, last reviewed on 1/18/2024, the P&P indicated the comprehensive care plans will be reviewed, revised, and completed within seven days after completion of the comprehensive assessment, which is prepared by the interdisciplinary team, that includes but is not limited to- a. A Registered Nurse with responsibility for the resident. b. Dietician c. The Resident and/or Resident's representative to the extent possible d. Respiratory Therapist e. Activities Representative f. Social Services g. Care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for one of five sampled residents (Resident 81) investigated under unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) the subcutaneous (SQ - beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: During a review of Resident 81's admission Record, the admission Record indicated the facility admitted the resident on 3/25/2023 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe] to facilitate breathing), and type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 81's History and Physical (H&P), dated 4/22/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 81's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/29/2024, the MDS indicated Resident 81 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 81 was receiving insulin. During a review of Resident 81's Physician Orders, the Physician Orders indicated the following: - 8/19/2024: Fingerstick blood sugar check every six with regular human insulin (a short acting insulin that starts to work within 30 minutes to 1 hour of injection) 100 units per milliliter (unit/ml - a unit of measurement) insulin per sliding scale (refers to the increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal) coverage as: 70 to 140 = zero unit (a unit of measurement); 141 to 180 = one unit; 181 to 200 = two units; 201 to 250 = three; 251 to 300 = four units; 301 to 350 = 6 units; 351 to 400 = eight units; more than (>) 400 call physician. - 8/19/2024: Humulin N NPH (an intermediate-acting insulin that takes 4 hours to start working after injection) U-100 insulin 100 units/ml suspension inject seven units SQ every 12 hours hold if blood sugar less than 100. During a concurrent interview and record review on 10/23/2024 at 3:30 p.m., reviewed Resident 81's Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident) from 8/2024, 9/2024, and 10/2024 with Registered Nurse 2 (RN 2), RN 2 verified the MAR indicated the Humulin N NPH and Regular insulin injection were administered as follows: For Humulin N: - 8/20/2024 6:00 a.m. SQ left lower quadrant (LLQ) - 8/20/2024 6:00 p.m. SQ LLQ - 8/22/2024 6:00 a.m. SQ right lower quadrant (RLQ) - 8/22/2024 6:00 p.m. SQ RLQ - 8/23/2024 6:00 a.m. SQ left upper quadrant (LUQ) - 9/2/2024 6:00 p.m. SQ LLQ - 9/3/2024 6:00 a.m. SQ LLQ - 9/4/2024 6:00 a.m. SQ RLQ - 9/4/2024 6:00 p.m. SQ RLQ - 9/5/2024 6:00 a.m. SQ LUQ - 9/5/2024 6:00 p.m. SQ LUQ - 9/7/2024 6:00 a.m. SQ RLQ - 9/7/2024 6:00 p.m. SQ RLQ - 9/16/2024 6:00 a.m. SQ LLQ - 9/16/2024 6:00 p.m. SQ LLQ - 9/20/2024 6:00 a.m. SQ RLQ - 9/20/2024 6:00 p.m. SQ RLQ - 10/4/2024 6:00 a.m. SQ left arm (LA) - 10/4/2024 6:00 p.m. SQ left arm (LA) - 10/15/2024 6:00 a.m. SQ RLQ - 10/15/2024 6:00 p.m. SQ RLQ - 10/17/2024 6:00 a.m. SQ RLQ - 10/17/2024 6:00 p.m. SQ RLQ Regular insulin: - 9/2/2024 12:00 p.m. SQ RLQ - 9/2/2024 6:00 p.m. SQ RLQ - 9/3/2024 12:00 a.m. SQ LLQ - 9/3/2024 6:00 a.m. SQ LLQ - 9/3/2024 12:00 a.m. SQ RLQ - 9/3/2024 6:00 a.m. SQ RLQ - 9/11/2024 6:00 a.m. SQ RLQ - 9/11/2024 12:00 p.m. SQ RLQ - 9/14/2024 6:00 p.m. SQ LLQ - 9/15/2024 12:00 a.m. SQ LLQ - 9/15/2024 6:00 p.m. SQ RLQ - 9/16/2024 12:00 a.m. SQ RLQ - 9/19/2024 6:00 p.m. SQ RLQ - 9/20/2024 12:00 a.m. SQ RLQ - 9/21/2024 6:00 a.m. SQ RLQ - 9/21/2024 12:00 p.m. SQ RLQ - 9/21/2024 6:00 p.m. SQ RLQ - 9/22/2023 6:00 a.m. SQ LLQ - 9/22/2023 12:00 p.m. SQ LLQ - 9/27/2024 6:00 p.m. SQ LLQ - 9/28/2024 12:00 a.m. SQ LLQ - 10/8/2024 6:00 a.m. SQ right upper quadrant (RUQ) - 10/8/2024 12:00 p.m. SQ RUQ - 10/9/2024 6:00 a.m. SQ LLQ - 10/9/2024 12:00 p.m. SQ LLQ - 10/12/2024 12:00 p.m. SQ RLQ - 10/12/2024 6:00 p.m. SQ RLQ - 10/14/2024 12:00 p.m. SQ LLQ - 10/14/2024 6:00 p.m. SQ LLQ - 10/16/2024 12:00 p.m. SQ RLQ - 10/16/2024 6:00 p.m. SQ RLQ RN 2 stated insulin administration should be rotated per standards of practice. RN 2 verified Resident 81's MAR indicated the insulin administration sites were not rotated. RN 2 stated not rotating the injection sites placed the resident at risk for developing bruising, pain, and tenderness (pain) on the administration sites. RN 2 stated that the skin underneath can develop lumps and affect the medication absorption. During a concurrent interview and record review on 10/25/2024 at 10:50 a.m., Residents 81's MARs on 8/2024, 9/2024, and 10/2024 were reviewed with the Director of Nursing (DON). The DON stated the nurses should rotate the insulin administration sites as a standard of practice. The DON stated the insulin administrated were not rotated on multiple occasions. The DON verified the manufacturer's guideline for the use of Humulin N and Regular Insulin indicated to rotate the injection sites. The DON stated the nurses did not follow the manufacturer's guideline and the standards of practice. The DON stated the insulin administration sites should have been rotated as it can affect the absorption of insulin and can also cause skin lumps and bruising. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed 1/18/2024, the P&P indicated to administer the insulin using proper subcutaneous technique. During a review of the facility provided manufacturer's guideline for Humulin R (insulin human), undated, the guideline indicated: - Change (rotate) the injection sites within the area chosen with each dose to reduce the risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. - Do not use the exact same spot for each injection. - Do not inject where the skin has pits, is thickened, or has lumps. - Do not inject where the skin is tender, bruised, scaly, or hard, or into scars or damaged skin. During a review of the facility provided manufacturer's guideline for Humulin N, undated, the guideline indicated: - Administer in the SQ tissue of the abdominal wall, thigh, upper arm, or buttocks. - To reduce the risk of lipodystrophy, rotate the injection site within the same region from one injection to the next.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate services to prevent decline in joint range of motion (ROM, full movement potential of a joint) for three out of nine sampled residents (Residents 15, 93, and 94) who had limited ROM and were assessed at risk for decline in joint ROM, as indicated in the resident's care plans. The facility failed to: 1. Ensure Resident 15 did not wear both hand splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for more than one hour as ordered by the physician. 2. Ensure Resident 93 wore both hand rolls (device to keep fingers open) at all times. 3. Ensure Resident 94 wore both hand rolls at all times and right heel protector at all times. These deficient practices had the potential to cause further decline in Residents 15, 93, and 94's ROM and skin integrity. Findings: 1. During a review of Resident 15's Record of admission (RA), the RA indicated the facility originally admitted Resident 15 to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including, chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and encephalopathy (any damage or disease that affects the brain). During a review of Resident 15's Annual History and Physical (H&P) dated 8/4/2024, the H&P indicated Resident 15 did not have the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/22/2024, the MDS indicated Resident 15 indicated Resident 15 required dependent assistance from staff for oral hygiene, toileting hygiene, upper and lower body dressing and rolling left to right in bed. The MDS also indicated Resident 15 had functional impairment in ROM on both sides of the upper and lower extremities. During a review of Resident 15's Physician's Orders (PO), the PO indicated on order dated 8/13/2018 for passive range of motion (PROM, movement at a given joint with full assistance from another person) to all extremities 10 to 15 minutes twice a day by RNA prior to splinting and an order dated 8/29/2022 for bilateral (both sides) hand splints twice a day [0700 to 0800 and 1300 and 1400] for one hour by RNA while resident is on his back [per family request]. During a review of Resident 15's care plan (CP) dated 8/2024, the CP indicated concerns and problems were limitations in the functional range of motion in the following areas: right (R) hip severe, left (L) hip moderate, R knee severe, L moderate, both ankle severe, both elbow functional range of motion, both wrists functional range of motion, both fingers functional range of motion, shoulder minimum. The care plan indicated the approach plan was for passive range of motion to all extremities once a day by RNA apply both hand splints (no time frame for wearing time was indicated). During an observation on 10/22/2024 at 12:22 p.m., Resident 15 was lying on the back in bed. Resident 15's right elbow was bent about halfway and the right wrist and hand was in a blue splint. Resident 15's left elbow was bent a little and the left wrist and hand was in a blue splint and rotated away from the body. During an observation on 10/22/2023 at 2:26 p.m., Resident 15 was lying in bed and both hand splints were on the resident's wrist/hands. During an observation on 10/23/2024 at 8:02 a.m., Resident 15 was lying in bed and there were no hand splints observed on either Resident 15's wrist/hands. During an interview on 10/23/2024 at 8:06 a.m., with Restorative Nursing Aide (RNA 1), RNA 1 stated Resident 15 did not receive his RNA treatment and the splints were not put on yet today. During an observation and interview on 10/23/2024 at 10:16 a.m. in Resident 15's room, RNA 1 completed the RNA treatment session for Resident 15. RNA 1 completed PROM exercises to both upper and lower extremities and put on both hand splints after PROM exercises to the upper extremities. RNA 1 stated Resident 15's order for the RNA were to put on the hand splints for two hours on, then take off the splints for two hours, and then put on the hand splints on for another two hours and then take them off for the rest of the day. RNA 1 stated during the RNA work shift from 7:00 a.m. to 3:00 p.m., the RNA needed to put on the splints twice in a day for two hours anytime during the workday. During an observation on 10/23/2024 at 12:39 p.m., Resident 15 was lying on his back in bed and both hand splints were on. During a concurrent interview and record review on 10/23/2024 at 1:16 p.m., with RNA 1, Resident 15's October 2024 RNA Charting Record was reviewed. RNA 1 stated RNA 1 completed PROM exercises to Resident 15 in the morning, then RNA 1 put on the hand splints for two hours. RNA 1 reviewed Resident 15's October RNA Charting Record and orders and stated the RNA order for Resident 15 actually said the hand splints should be put on for one hour, not two hours, but RNA 1 stated she had been putting it on for at least two hours. RNA 1 stated based on the physician's order, RNA should only be putting on the hand splints for one hour at a time. RNA 1 stated if RNAs completed something different than the order, then we (RNAs) should tell the charge nurse. During a concurrent interview and record review of Resident 15's Physician's Orders, on 10/23/2024 at 1:50 p.m., with Registered Nurse 1 (RN 1), RN 1 stated the RNA order indicated the hand splints should be put on for one hour during the hours of 7:00 a.m. and 8:00 a.m., then put the hand splints on again for one hour during the hours of 1:00 p.m. and 2:00 p.m. RN 1 stated if the splints were put on for more than one hour as ordered, then the splints could cause redness of the skin or irritation where the splints were on. During a concurrent interview and record review of Resident 15's Physician's Orders, on 10/23/2024 at 2:17 p.m., with the Director of Rehabilitation (DOR), the DOR stated Resident 15's RNA order indicated both hand splints should be put on for one hour at a time. The DOR stated if the splints were put on longer than ordered, then a resident could develop skin lesions. The DOR stated a splint helps prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and to prevent skin on skin contact and maintain skin integrity. During an interview on 10/23/2024 at 4:22 p.m., with the Director of Nursing (DON), the DON stated the purpose of a splint is to prevent further contractures and to have proper alignment for the joints. The DON stated if a resident wore a splint for longer than ordered, it could cause skin breakdown and stiffness in the joints. DON stated the RNAs should be following the RNA orders. During a review of the facility's policy and procedure (P&P) revised 5/16/2019, titled, Hand Splints and Rolls, the P&P indicated the physician/nurse practitioner writes an order for treatment indicating the length of time splints are to remain on and off. Splints will be applied and removed according to the physician's order. 2. During a review of Resident 93's Record of Admission, the RA indicated the facility originally admitted Resident 93 on 9/11/2023 and readmitted the resident on 7/9/2024 with diagnoses including chronic respiratory failure and spastic diplegia cerebral palsy (is a group of disorders that affect a person's ability to move and maintain balance and posture with tightness in lower extremities). During a review of Resident 93's MDS dated [DATE], the MDS indicated Resident 93 was severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 93 had functional range of motion limitations on both sides of both the upper and lower extremities. The MDS also indicated Resident 93 required dependent assistance from staff for oral hygiene, toileting hygiene, upper and lower body dressing, and rolling left and right in bed. During a review of Resident 93's Physician's Order, the PO indicated an order dated 7/9/2024 for use both hand rolls at all times. During a review of Resident 93's care plan (CP) dated 9/16/2024 for potential for limitations in the range of motion in all extremities, the CP indicated the approach plan was to apply splints/braces and any devices properly when ordered and to use bilateral hand rolls at all times. During an observation and interview on 10/22/2024 at 1:13 p.m. with Licensed Vocational Nurse (LVN 3) in Resident 93's room, LVN 3 stated Resident 93's hand rolls were not put on correctly. LVN 3 stated both hand rolls were around Resident 93's wrists and the cushioned part was not put in Resident 93's hands. LVN 3 proceeded to straighten the fingers on both hands and moved both hand rolls from the wrist and put the cushioned portion inside Resident 93's hands. LVN 3 stated hand rolls were to help residents who could not open their hands and to prevent redness on skin and prevent moisture inside the hands which could cause the skin to open and lead to an infection. During an interview on 10/23/2024 at 1:50 p.m., with Registered Nurse 1 (RN 1), RN 1 stated hand rolls were used to help prevent contractures in a fisted position. RN 1 stated if there was an order for hand rolls to be on at all times, then the hand rolls should be on the resident's hands at all times. RN 1 stated if a resident did not have a hand roll on, but it was ordered, then the resident's fingers could be in a fisted position and if their nails were long, then the nails could cut into their palms. During an interview on 10/23/2024 at 4:22 p.m., the Director of Nursing (DON), the DON stated staff should follow orders for hand rolls and hand rolls should be placed on residents properly, because hand rolls are used to help prevent contractures. The DON if staff were not applying the hand rolls in the proper place, the residents could develop skin breakdown. During a review of the facility's policy and procedure (P&P) revised 5/16/2019, titled, Hand Splints and Rolls, the P&P indicated residents identified as needing hand rolls will receive an order from the physician. Once an order has been received from the physician, the order will be noted and carried out. 3. During a review of Resident 94's Record of Admission, the RA indicated the facility admitted Resident 94 on 9/11/2023 with diagnoses including dependence on supplemental oxygen and cerebral palsy. During a review of Resident 94's MDS dated [DATE], the MDS indicated Resident 94 was severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 94 had functional range of motion limitations on both sides of both the upper and lower extremities. The MDS also indicated Resident 15 required dependent assistance from staff for oral hygiene, toileting hygiene, upper and lower body dressing, and rolling left and right in bed. During a review of Resident 94's Physician's Order, the PO indicated an order dated 10/16/2023 for use both hand rolls at all times and an order dated 10/16/2023 for use both heel protectors at all times. During a review of Resident 94's care plan dated 9/11/2023 and re-evaluated 9/2024, for potential for limitations in the range of motion in all extremities, the CP indicated the approach plan was to apply splints/braces and any devices properly when ordered. During a concurrent observation and interview on 10/22/2024 at 1:03 p.m., with Licensed Vocational Nurse (LVN 2), observed Resident 94 lying on the back in bed and the right elbow was fully bent, the right wrist was straight, the right hand was in a fisted position. A blue hand roll was observed on the bed to the right of the resident. Resident 94's left elbow was bent about halfway, the left wrist was mostly straight, and the left hand was in a fisted position. There were no hand rolls observed on Resident 94. LVN 2 stated Resident 94 should have hand rolls in both hands at all times and heel protectors on both feet. LVN 2 stated Resident 94 was not wearing hand rolls at this time. LVN 2 stated the right heel protector was not on. LVN 2 proceeded to put on the right heel protector and right hand roll for Resident 94. Licensed Vocational Nurse (LVN 3) entered the room and assisted to put on the hand roll on Resident 94's left hand. LVN 3 stated Resident 94 was supposed to have both hand rolls and both heel protectors on at all times because Resident 94 could not open his own hands. LVN 3 stated hand rolls were to help residents who could not open their hands and to prevent redness on skin and prevent moisture inside the hands which could cause the skin to open and lead to an infection. During an interview on 10/23/2024 at 1:50 p.m., with Registered Nurse 1 (RN 1), RN 1 stated hand rolls are used to help prevent contractures in a fisted position. RN 1 stated if there was an order for hand rolls to be on at all times, then the hand rolls should be on the resident's hands at all times. RN 1 stated if a resident did not have a hand roll on, but it was ordered, then the resident's fingers could be in a fisted position and if their nails were long, then the nails could cut into their palms. RN 1 stated the heel protectors protect residents from putting pressure on their heels so if a resident did not have heel protectors on when they were ordered to be put on, the residents could definitely develop a pressure injury. During an interview on 10/23/2024 at 4:22 p.m., with the Director of Nursing (DON), the DON stated staff should follow orders for hand rolls and hand rolls should be placed on residents properly, because hand rolls are used to help prevent contractures. The DON if staff were not applying the hand rolls in the proper place, the residents could develop skin breakdown. A review of the facility's policy and procedure revised 5/16/2019, titled, Hand Splints and Rolls, indicated residents identified as needing hand rolls will receive an order from the physician. Once an order has been received from the physician, the order will be noted and carried out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for four of four sampled residents (Residents 19, 35, 100, and 87) by failing to ensure: 1. Resident 19's albuterol (a medication to prevent and treat wheezing and shortness of breath caused by breathing problems) and Atrovent (a medication to make breathing easier) medications were not left at the bedside. 2. Resident 35's bottle of milk of magnesia (a medication to treat constipation, upset stomach and heart burn) was not left at the bedside. 3. Resident 100's fall mat (a floor mat designed to reduce the risk of injury from a fall by providing a soft-landing surface) did not have medical equipment or furniture on top of them for a longer period of time. 4. Resident 87's bed was placed on the lowest position by the X-ray Tech (a healthcare professional who performs medical examinations using X-rays [a test or way for physicians to get pictures of the inside of the body using radiation { energy that moves from one place to another in a form that can be described as waves or particles}] on patients to create images of specific parts of the body) after X-ray examination was completed. These deficient practices had the potential to result in serious harm or death to the residents. Findings: 1. During a review of Resident 19's admission Record (AR), the AR indicated the facility admitted the resident on 1/2/2019, and readmitted the resident on 4/20/2020, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), dependence on respirator (a mechanical device that helps a patient breathe by moving air into and out of their lungs), and tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs). During a review of Resident 19's History and Physical (H&P), dated 4/16/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 19's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/9/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. During a review of Resident 19's physician orders (PO), the PO indicated and order for: 7/18/2022: Albuterol HFA (a medication commonly used by people with asthma) 2 puffs via metered-dose-inhaler (MDI, a device used to deliver medication into the lungs) twice a day (BID). Monitor heart rate (HR) before and after mediation administration 1/18/2023: Albuterol 2.5 miligrams unit dose via hand-held nebulizer a device that delivers liquid medication as an aerosol to help treat respiratory symptoms) every (q) 2 hours if needed (PRN) shortness of breath (SOB)/wheezing. The physician orders did not indicate an active order for Atrovent. During a concurrent observation and interview on 10/22/2024, at 10:41 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 19's room, Resident 19's Atrovent and albuterol medications were in a transparent pouch hanging on the feeding pump pole of the resident. LVN 1 stated the Atrovent, and the albuterol medications should not be left at the bedside of the resident because it can be a safety issue. LVN 1 stated it was the responsibility of the staff to ensure the medications were stored in a safe place to prevent the resident from accidental overdosing with the medications. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated medications should not be left at the bedside of the resident unless there is an order from the physician for the resident to take their own medication and the interdisciplinary team (IDT, a group of professionals from different fields who work together to achieve a common goal) has deemed the resident safe to take his own medications. The DON stated leaving the medications at the bedside had a potential for the resident to over or under dose the intake of medications that can affect the resident's health. During a review of the facility's recent policy and procedure (P&P) titled Self-Administration of Medications, last reviewed on 1/18/2024, the P&P indicated nursing/IDT and physician will assess resident's physical and mental status and determine if a resident has the capability to self-administer medications. If resident is deemed appropriate, a Physician's order will be obtained for self-administration of medication upon resident's request. During a review of the facility's recent policy and procedure (P&P) titled All Saints Healthcare Patient Safety Plan, last reviewed on 1/18/2024, the P&P indicated employees are required to participate in safety activities not only to job descriptions but system-wide proceedings as appropriate. Individual behaviors and actions will support system-wide improvement of safety for patients, visitors, and the staff. Specific activities include but are not limited to: actively reporting errors, near misses, good catches, and hazardous conditions as the given situation recognized. 2. During a review of Resident 35's admission Record (AR), the AR indicated the facility admitted the resident on 3/31/2014, and readmitted the resident on 7/17/2017, with diagnoses including chronic respiratory failure, dependence on respirator, and tracheostomy. During a review of Resident 35's H&P, dated 8/13/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. During a review of Resident 35's physician orders (PO), dated 12/27/2023, the PO indicated an order for milk of magnesia 30 cubic centimeter (cc, a unit of volume) orally every night (qHS) if needed (PRN) if no bowel movement (BM) for 2 days (X2) days (constipation, a condition in which stool becomes hard, dry, and difficult to pass, and bowel movements do not happen very often). During a concurrent observation and interview on 10/22/2024, at 10:41 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 35's room, Resident's 35's bottle of milk of magnesia was at the resident's bedside table. LVN 1 stated the bottle of milk of magnesia should not be left at the bedside of the resident because it can be a safety issue. LVN 1 stated it was the responsibility of the staff to ensure the medications were stored in a safe place to prevent accidental overdosing of residents with medications. During an interview on 10/25/2024, at 1:55 p.m., with the DON, the DON stated medications should not be left at the bedside of the resident unless there is an order from the physician for the resident to take their own medication and the IDT has deemed the resident safe to take his own medications. The DON stated leaving the medications at the bedside had a potential for the resident to over or under dose the intake of medications that can affect the resident's health. During a review of the facility's recent policy and procedure (P&P) titled Self-Administration of Medications, last reviewed on 1/18/2024, the P&P indicated nursing/IDT and physician will assess resident's physical and mental status and determine if a resident has the capability to self-administer medications. If resident is deemed appropriate, a Physician's order will be obtained for self-administration of medication upon resident's request. During a review of the facility's recent policy and procedure (P&P) titled All Saints Healthcare Patient Safety Plan, last reviewed on 1/18/2024, the P&P indicated employees are required to participate in safety activities not only to job descriptions but system-wide proceedings as appropriate. Individual behaviors and actions will support system-wide improvement of safety for patients, visitors, and the staff. Specific activities include but are not limited to: actively reporting errors, near misses, good catches, and hazardous conditions as the given situation recognized. 3. During a review of Resident 100's admission Record (AR), the AR indicated the facility admitted the resident on 1/6/2024, and readmitted the resident on 1/6/2024, with diagnoses including, chronic respiratory failure, traumatic hemorrhage of cerebrum (bleeding in the brain that occurs after a traumatic head injury), and convulsions (a condition where a person's muscles contract and relax rapidly and uncontrollably, causing shaking and limb movement). During a review of Resident 100's H&P, dated 1/8/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 100's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had highly impaired vision and was dependent to needing substantial/maximal assistance on mobility and activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 10/22/2024, at 10:12 a.m., with Licensed Vocational Nurse 13 (LVN 13), in Resident 100's room, Resident 100 was lying in bed with the fall mat at the right side of the bed, and the bed's wheels were resting on top of the fall mat. LVN 13 stated the resident was a fall risk that was why the resident had a fall mat and a 1:1 sitter (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act). LVN 13 stated the fall mat should not be left with a heavy furniture on top of them because it will squish the mat not serving its purpose to lessen the impact of the resident's fall to prevent injury. During an interview on 10/25/2024, at 1:55 p.m., with the DON, the DON stated the sitter should be attentive to the resident's environment, they should make sure the resident is safe and environmental hazards are identified and acted upon to prevent accidents. The DON stated the sitter should have seen the fall mat with the resident's bed on top of them and fixed the placement of the mat. The DON stated the failure of the sitter to fix the placement of the mat can cause injury to resident when they fall due to its placement, and it could damage the fall mat due to the wheels of the bed resting on top of the mat causing a permanent dent on the mat decreasing its cushioning effect to absorb resident's impact of fall. During a review of the facility's recent policy and procedure (P&P) titled . Healthcare Patient Safety Plan, last reviewed on 1/18/2024, the P&P indicated employees are required to participate in safety activities not only to job descriptions but system-wide proceedings as appropriate. Individual behaviors and actions will support system-wide improvement of safety for patients, visitors, and the staff. Specific activities include but are not limited to: actively reporting errors, near misses, good catches, and hazardous conditions as the given situation recognized. During a review of the facility provided manufacturer's guideline on the use of Medline Beveled Floor Mat, undated, the guideline indicated to never leave heavy materials on the mat for an extended amount of time and they may cause a permanent indentation. 4. During a review of Resident 87's admission Record , the admission Record indicated the facility admitted the resident on 5/8/2023 and readmitted in the facility on 6/19/2024 with diagnoses including but not limited to chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe] to facilitate breathing), and gastrostomy tube (also known as G-Tube - a tube inserted through the abdomen that delivers nutrition directly to the stomach). During a review of Resident 87's History and Physical (H&P) dated 6/21/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 87's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/26/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 87 had impairment of both upper and lower extremities. During a review of Resident 87 fall risk assessment dated [DATE], the assessment indicated Resident 87 was a high risk for falls. During a review of Resident 87's care plan on potential for falls and injury related to impaired cognition, decreased mobility, and able to balance self and turn to side initiated 6/21/2024 and last reviewed 9/2024, it indicated the following interventions to free resident from falls and injury: - Monitor at frequent intervals to ensure safety. - Provide a well-lighted and safe environment. During an observation on 10/22/2024 at 10:35 a.m., Resident 87's room, X-ray Tech placed the resident's bed in high position, and performed an x-ray. During a concurrent observation and interview on 10/22/2024 at 10:55 a.m. with Licensed Vocational Nurse 12 (LVN 12), inResident 87's room, Resident 87's bed in a high position. LVN 12 stated bed should be maintained at a safe position to prevent the residents from falling out of bed due to involuntary movements when they cough. LVN 12 verified the X-ray Tech left Resident 87's bed in a high position. LVN 12 measured Resident 87's height of bed as 35 inches from the top of the mattress to the floor. LVN 12 adjusted the height of bed and stated there was room to lower down the height of bed. LVN 12 stated the X-ray Tech should have placed Resident 87's bed back in a lower position for safety to prevent falls and injury. During a concurrent observation and interview on 10/22/2024 at 10:55 a.m. with the Director of Nursing (DON), outside Resident 87's room, DON verified that the bed was left by in a high position. The DON stated Resident 87's bed should have been placed in a low position by the X-ray Tech after completion of the x-ray and staff to monitor safe positioning of beds during rounds to prevent the resident from falls which may lead to injury. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention, Precautions, and Assessment, last reviewed 1/18/2024, the P&P indicated a purpose to ensure that residents who are at risk for falls are identified, preventive measures are implemented, and falls are tracked and trended. The P&P indicated residents will be placed in the beds with all safety measures/devices in place and reassess for before leaving the bedside. During a review of the facility's policy and procedure (P&P) titled, Accident Prevention, last reviewed 1/18/2024, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P&P titled, Resident Supervision, last reviewed 1/18/2024, the P&P indicated: -The DON, Unit Managers, and Charge Nurse make daily rounds to monitor resident safety and care. -Primary Nurses (PN) and Respiratory Therapists (RT - a health professional who helps patients with breathing problems or lung disorders) are responsible are responsible for the care and safety of their assigned residents during their shift. -Certified Nursing Assistants, Licensed Nurses, and RT are often assigned one one to one sitting to monitor certain residents for safety and care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent (having no or insufficient control) of bladder (an organ inside the body that stores urine until it can be excreted) received appropriate treatment and services to prevent urinary tract infection (UTI, an infection in the bladder/urinary tract) for three of four sampled residents (Residents 80, 7, and 94) being investigated under urinary catheters (a hollow tube inserted into the bladder to drain or collect urine) by failing to ensure: 1. Resident 80's suprapubic catheter (a medical device that helps drain urine from the bladder) had a securement device/anchor (a device that support the weight of the leg bag and keeps a urinary catheter in place). 2. Residents 7 and 94's urinary catheter tubing systems were not coiled while hanging off the sides the beds. These deficient practices had the potential for Residents 80, 7, and 94 to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it can be excreted]). Findings: 1. During a review of Resident 80's Record of Admission, the Record of admission indicated the facility admitted the resident on 3/20/2023 and readmitted on [DATE], with diagnoses including tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and pressure ulcer of sacral region (skin injuries that occur in the sacral region of the body, near the lower back and spine). During a review of Resident 80's History and Physical (H&P), dated 7/12/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 80's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/17/2024, the MDS indicated the resident had a suprapubic catheter. During a review of Resident 80's Physician's Order, dated 10/17/2024, the order indicated to remove Foley catheter (a brand of urinary catheter also known as indwelling catheter, a soft, thin, flexible tube placed into the bladder to drain urine) in 24 hours. During a review of Resident 80's Physician's Order, dated 10/18/2024 at 6 p.m., the order indicated to change suprapubic dressing as needed, suprapubic catheter: Flush with 60 milliliters (ml, a unit of volume) normal saline (NS, a mixture of water and salt) every (q) shift, and suprapubic catheter # 16 X 10: change q month and if needed (prn) when out or plugged (every 16th of the month) (diagnosis: urinary retention, a condition that makes it difficult or impossible to empty the bladder). During a review of Resident 80's Care Plan titled, At risk for UTI, last evaluated on 10/2024, indicated a patient goal that the resident will not have any signs of UTI. During a concurrent observation and interview on 10/22/2024, at 9:43 a.m., with Licensed Vocational Nurse 8 (LVN 8), inside Resident 80's room, Resident 80's suprapubic catheter was not anchored with a securement device/ leg strap. LVN 8 stated there should be a securement device in place on the suprapubic catheter of Resident 80 to prevent pulling and tugging that can cause trauma and break in the tissues of the stoma (a surgically created opening in the body that connects an internal area to the outside) where infection can set in. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated the staff should ensure the suprapubic catheter should have a leg strap to prevent pulling and trauma to the stoma of the resident. The DON stated the trauma can cause break in the skin, and it can be a portal of entry for infection that can lead to UTI. During a review of the facility's recent policy and procedure (P&P) titled, Catheter Care and Urinary Bag Privacy Cover, last reviewed on 1/18/2024, the P&P indicated to secure tubing to patient's thigh with Catheter Posey or Fabric leg strap. 2. During a review of Resident 7's Record of Admission, the admission Record indicated the facility admitted the resident on 7/26/2000 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy, and anoxic brain damage (a condition caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). During a review of Resident 7's History and Physical (H&P), dated 11/26/2023, the H&P indicated Resident 7 did not have the capacity to understand and make decisions due to anoxic encephalopathy (also known as anoxic brain damage). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 was rarely or never understood, had impairment on both upper and lower extremities, was dependent on facility staff for activities of daily living such as hygiene, toileting, dressing, and surface-to-surface transfers, and had an indwelling catheter in place. During a review of Resident 7's Physician Orders, the physician orders indicated the following: - 11/23/2018: Irrigate Foley catheter with 60 ml normal saline (NS - a saltwater solution) as needed plugging or cloudiness. - 8/27/2019: Dignity bag (privacy cover) for Foley catheter in place at all times and monitor every shift. - 4/3/2020: Foley catheter 16 French (Fr, a measurement system for the diameter of a catheter tube) by ten ml: change every monthly second of the month and as needed when out or plugged for urinary retention (a condition in which urine cannot empty from the bladder). During a review of Resident 7's care plan (CP), initiated on 11/10/2023 and last reviewed on 8/2024, the CP indicated Resident 7 was at risk for UTI related to the Foley catheter. The CP further indicated to keep the Foley catheter tubing free from coils and bag below the waist as on the interventions to prevent any signs and symptoms of UTI. During a concurrent observation and interview with Licensed Vocational Nurse 4 (LVN 4), on 10/22/2024, at 10:30 a.m., inside Resident 7's room, LVN 4 confirmed Resident 7's urinary catheter tubing was coiled below Resident 7's bed and stated when the urinary catheter tubing is coiled, Resident 7's urine would not flow freely into the collection bag. LVN 4 stated when a urinary catheter tubing is coiled, there is a potential for infection and tugging and dislodgement of the urinary catheter. During an interview with the Director of Nursing (DON), on 10/25/2024, at 2:30 p.m., the DON stated the urinary catheter bag should be below the bladder area and not coiled so that the urine can drain properly. The DON stated the urinary catheter tubing should be in line with the drainage bag with no coiling to prevent urinary retention, which can potentially cause UTIs. During a review of the facility's policy and procedure (P&P) titled, Catheter Care and Urinary Bag Privacy Cover, last reviewed 1/18/2024, the P&P indicated to check the position of tubing for no kinks and that it is attached to the bed so there are no loops between the mattress and drainage bag. 3. During a review of Resident 94's Record of Admission, the Record of admission indicated the facility originally admitted the resident on 9/11/2023 with diagnoses including neuromuscular dysfunction of the bladder (also known as neurogenic bladder, a condition that occurs when the nerves and muscles of the bladder don't communicate properly with the brain, resulting in bladder control issues). During a review of Resident 94's MDS, dated [DATE], the MDS indicated Resident 94 was rarely or never understood, had impairment on both upper and lower extremities, was dependent on facility staff for activities of daily living such as hygiene, toileting, dressing, and surface-to-surface transfers, and had an indwelling catheter in place. During a review of Resident 94's Physician's Progress Note, dated 9/14/2023, the physician's progress note indicated Resident 94 had severe neurologic impairment (dysfunction in the brain or nervous system) and had a suprapubic catheter in place. During a review of Resident 94's Physician Orders, the physician orders indicated Resident 94 was ordered the following: - On 9/11/2023, flush suprapubic catheter with 240 ml sterile water twice a day. - On 9/11/2023, change suprapubic catheter 16 French every two weeks and as needed out or plugged. - On 9/19/2023, dignity bag for suprapubic catheter in place at all times and monitor every shift. During a review of Resident 94's Care Plan, dated 9/17/2024, the care plan indicated Resident 94 was at risk for UTI related to neurogenic bladder, a suprapubic catheter, and recurrent infections. The care plan further indicated the approach plan included keeping the suprapubic catheter tubing free from coils and dignity bag in place at all times and to monitor every shift. During an observation on 10/22/2024, at 10:24 a.m., inside Resident 94's room, Resident 94's urinary catheter tubing was connected to the resident and hung off the side of the resident's bed. The urinary catheter tubing coiled below the bed and contained light yellow liquid with white colored sediment. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3, on 10/22/2024, at 10:30 a.m., inside Resident 94's room, LVN 3 confirmed Resident 94's urinary catheter tubing coiled below Resident 94's bed and stated when the urinary catheter tubing is coiled, Resident 94's urine would not flow freely into the collection bag. LVN 3 further stated when a urinary catheter tubing is coiled, there is a potential for infection and tugging and dislodgement of the urinary catheter. During an interview with the Director of Nursing (DON), on 10/22/2024, at 4:45 p.m., the DON stated the urinary catheter bag should be below the umbilical area (relating to the navel) so that the urine can drain properly. The DON further stated the urinary catheter tubing should be in line with the drainage bag with no coiling to prevent urine retention, which can potentially cause UTIs. During a review of the facility's policy and procedure (P&P) titled, Catheter Care and Urinary Bag Privacy Cover, last reviewed on 1/18/2024, the P&P indicated to check the position of tubing for no kinks and that it is attached to the bed so there are no loops between the mattress and drainage bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. During a review of Resident 104's admission Record, the admission Record indicated the facility admitted the resident on [DATE] and readmitted on [DATE], with diagnoses including gastrostomy, dysphagia (difficulty swallowing), and gastro-esophageal reflux disease (GERD, a chronic condition that occurs when stomach contents leak into the esophagus). During a review of Resident 104's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had a feeding tube and on a therapeutic diet. During a review of Physicians Orders (PO), dated [DATE], the PO indicated an order to check tube placement prior to feeding/administration of medications every (q) shift. During a concurrent observation and interview on [DATE], at 9:39 a.m., with LVN 1, inside Resident 104's room, observed Resident 104's irrigation tray dated [DATE] placed on the ventilator stand. LVN 1 stated the irrigation tray was old and the date on the irrigation tray was [DATE]. LVN 1 stated the night shift staff should have changed it to prevent the resident to develop gastrointestinal infection (an inflammation or irritation of the digestive tract, often caused by bacteria, viruses, or parasites). During an interview on [DATE], at 1:55 p.m., with the DON, the DON stated the staff should ensure the irrigation tray for feeding the resident via gastrostomy tube to prevent infection to resident causing gastro- intestinal problems such as abdominal distention, nausea, and vomiting (N&V), and loose stools. During a review of the facility's recent P&P titled Infection Control Program, last reviewed on [DATE], the P&P indicated the facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for Residents and staff to help prevent the development and transmission of disease and infection. e. During a review of Resident 65's admission Record, the admission Record indicated the facility admitted the resident on [DATE], with diagnoses including dependence on respirator (a mechanical device that helps a patient breathe by moving air into and out of their lungs), gastrostomy, and type 2 diabetes mellitus. During a review of Resident 65's H&P, dated [DATE], the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 65's MDS, dated [DATE], the MDS indicated the resident was on a feeding tube and on a therapeutic diet. During a review of Resident 65's Physician Orders (PO), dated [DATE], the PO indicated an order for enteral supply kit (used to feed patients unable to chew and/or swallow) (and pole) every day. During a concurrent observation and interview on [DATE], at 9:39 a.m., with LVN 1, inside Resident 65's room, observed Resident 65's irrigation tray dated [DATE] placed on the ventilator stand. LVN 1 stated the irrigation tray was old and the date on the piston syringe was [DATE]. LVN 1 stated the night shift staff should have changed it to prevent the resident to develop gastrointestinal infection. During an interview on [DATE], at 1:55 p.m., with the DON, the DON stated the staff should ensure the irrigation set for feeding the resident via g-tube to prevent infection to resident causing gastrointestinal problems such as abdominal distention, N&V, and loose stools. During a review of the facility's recent P&P titled Infection Control Program, last reviewed on [DATE], the P&P indicated the facility shall establish and infection control program designed to provide a safe, sanitary, and comfortable environment for Residents and staff to help prevent the development and transmission of disease and infection. Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate care and services to prevent complications of enteral feeding for six of six sampled residents (Residents 75, 38, 11, 104, and 65) investigated under the tube feeding care area by: 1. Failing to ensure Licensed Vocational Nurse 5 (LVN 5) discarded the EF formula that remained in Resident 75's irrigation bottle after medication administration with the medication syringe left inside. 2. Failing to ensure Resident 38's EF formula bottle indicated the start date. 3. Failing to ensure Resident 11's EF bag was labeled with the resident's name, date and time, and the licensed nurse's initials when it was changed. These deficient practices had the potential for Residents 75, 38, and 11 to experience gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea. 4. Failing to ensure the irrigation tray (a medical device used to irrigate feeding tubes) for feeding was changed per facility policy. This deficient practice had the potential to result in altered nutritional status that can lead to complications such as gastritis (a condition that occurs when the stomach lining becomes inflamed, swollen, and red) from ingesting expired formula and water flush. Findings: a. During a review of Resident 75's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe] to facilitate breathing), and gastrostomy (G-tube, a surgical procedure used to insert a tube through the abdomen and into the stomach). During a review of Resident 75's History and Physical (H&P), dated [DATE], the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 75's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 75 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MD indicated Resident 75 received G-tube feeding. During a review of Resident 75's Physician Orders, the Physician Orders indicated the following orders: - [DATE]: Check gastric residual and tube placement every four hours, hold feeding if residual 100 milliliters (ml - a unit of measurement) and above, recheck after 2 hours. Call physician if residual remains 100 ml. - [DATE]: Flush 50 ml water via G-tube before and after medication administration. - [DATE]: Check tube placement prior to monitor to feeding or administration of medications every shift. - G-tube feeding: Jevity 1.2 (a type of feeding formula with fiber, for people with, or at risk of developing disease-related malnutrition) at 50 ml per hour (ml/hr - a unit of measurement) via pump to provide 1,100 ml per 1,320 kilocalories (Kcal - a unit of measurement) for 22 hrs per day every 24 hrs average 2 hrs off for bath, therapy, medication administration. - Flush feeding tube with 220 ml water every 24 hrs to provide 1320 mml/day. During a concurrent observation and interview on [DATE] at 9:55 a.m. in Resident 75's room with Licensed Vocational Nurse 5 (LVN 5), observed Resident 75's irrigation bottle for medication administration with at least 10 ml of light brown colored liquid with the tip of medication syringe touching the liquid inside the bottle. LVN 5 stated the light brown liquid inside the irrigation bottle was EF formula at least 10 ml and that she forgot to discard and wash the irrigation bottle and medication syringe after checking the G-tube for placement, and presence of residuals, and medication administration. LVN 5 stated she should have discarded the EF formula inside the irrigation bottle and wash the bottle and syringe after use to ensure they are clean for the next use and can be an infection control issue. LVN 5 stated not discarding the EF formula had the potential for the formula to get spoiled in the irrigation bottle with the tip of medication syringe touching the formula which may lead to signs of feeding intolerance such as nausea, vomiting, and diarrhea. During a concurrent interview and record review on [DATE] at 11:03 a.m. with the Minimum Data Set Coordinator (MDSC), reviewed Resident 75's medical records including care plan (CP). MDSC stated Resident 75 had a CP addressing presence of G-tube feeding at risk for potential intolerance of artificial nutrition. The CP indicated to check tube placement, patency, and residuals prior to administration of feeding, medications, and water flush, and observe for signs and symptoms of feeding intolerance such as nausea, vomiting, and diarrhea as some of the interventions. The MDSC stated after checking for tube placement, gastric residuals, and administration of medications, the irrigation bottle and medication syringe should have been washed thoroughly. The MDSC stated that any feeding formula left inside the irrigation bottle with the medication syringe inside may get spoiled and lead to signs and symptoms of feeding intolerance such as nausea, vomiting, and diarrhea. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding - General Policy, last reviewed [DATE], the P&P indicated proper hand-washing technique shall be used when handling enteral equipment. During a review of the facility's P&P titled, Infection Control Program, last reviewed [DATE], indicated the facility shall establish and infection control program designed to provide a safe, sanitary, and comfortable environment for Residents and staff to help prevent the development and transmission of disease and infection. b. During a review of Resident 38's admission Record indicated the facility admitted the resident on [DATE] and readmitted in the facility on [DATE] with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. During a review of Resident 38's H&P, dated [DATE], the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 38's MDS, dated [DATE], the MDS indicated Resident 38 had severely impaired cognition and required total assistance from staff with all ADLs. The MD indicated Resident 38 received G-tube feeding. During a review of Resident 38's Order Summary Report, the Order Summary Report indicated the following: - [DATE]: Check gastric residual and tube placement every four hours, hold feeding if residual 100 ml and above, recheck after 2 hours. Call physician if residual remains 100 ml. - [DATE]: Flush G-tube with 50 ml water before and after medication administration and 5 to 10 ml in between medications. - [DATE]: Check tube placement prior to monitor to feeding or administration of medications every shift. - G-tube feeding: Jevity 1.2 at 70 ml/hr via pump to provide 1,540 ml/ 1,840 Kcals for 22 hrs per day every 24 hrs average 2 hrs off for bath, therapy, medication administration. - Flush feeding tube with water 90 ml/hr for 22 hrs to provide 1,980 ml/day. During a concurrent observation and interview on [DATE] at 11:14 a.m. incident Resident 38's room with LVN 4, observed Resident 38's EF bottle infusing and did not indicate the date it was started. LVN 4 confirmed that the EF bottle did not indicate the date it was started. LVN 4 stated EF bottle should indicate the resident's name, room number, infusion rate, and the date and time the bottle was hung for staff to be aware that the formula was not expired. During an interview on [DATE] 9:00 a.m. with the Director of Nursing (DON), the DON stated per facility practice and policy, the EF bottle should be labeled with the time, date, resident's name, and nurse's initials when hung. The DON stated the licensed nurse should have completed the label in the EF bottle to include the time, date, resident's name, and nurse's initials with every bottle prior to hanging to ensure staff are aware that the formula is not expired which may lead to signs and symptoms of feeding intolerance such as nausea, vomiting, and diarrhea. During a review of the facility's P&P titled, Enteral Feeding - General Policy, last reviewed [DATE], the P&P indicated: - Label the formula with time, date, resident's name, and nurse's initials when hung. - Administration bag and/or tubing shall be labeled with the date and time and nurse's initials when changed. During a review of the facility's P&P titled, Administration of Enteral Formula via Pump, last reviewed [DATE], the P&P indicated to label the formula with the patient's name, room, date, time, rate, and initial. c. During a review of Resident 11's admission Record, the admission Record indicated the facility originally admitted the resident on [DATE] and readmitted on [DATE], with diagnoses including cerebral palsy (a group of conditions that affect movement and posture) and gastrostomy. During a review of Resident 11's Annual H&P, dated [DATE], the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 11's Physician's Orders (PO), dated [DATE], the PO indicated GT feeding of Enteral Formula 1 (EF 1) at 240 ml bolus (set amount of formula/liquid nutrition given in a short time) every three hours to provide 1,920 ml /2,888 kilocalories (kcal-a unit of measure) to promote weight gain. During a review of Resident 11's MDS, dated [DATE], the MDS indicated the resident rarely had the ability to make self-understood and sometimes understand others. The MDS indicated Resident 11 was dependent on ADLs and had a feeding tube (also known as GT) while a resident in the facility. During a review of Resident 11's Care Plan (CP) addressing the presence of GT, last re-evaluated 10/2024, the CP indicated the resident with goals of free from any irritation or infection on GT site with interventions including administering feeding formula as ordered. During a concurrent observation and interview on [DATE] at 12:46 p.m., at Resident 11's bedside with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the formula labeled EF 1 hung with no patient name, no date and no time written on it. CNA 1 stated she does not know who it belongs to because there was no name. During a concurrent observation and interview on [DATE] at 12:52 p.m., at Resident 11's bedside with LVN 1, LVN 1 stated she forgot to label it with the resident's information and when she prepared it. LVN 1 stated she was the one who prepared and capped the tubing for infection control. LVN 1 stated she needs to label it for the right resident and know when it is not good to administer. LVN 1 stated the enteral formula has a shelf-life of 24 hours after it has been punctured. LVN 1 stated the potential of not labeling the enteral formula could potentially administer spoiled enteral nutrition. During an interview on [DATE] at 4:41 p.m., the DON stated when the licensed nurses hung a new tube feeding formula and new tubing, they are expected to label the formula with the resident's name and the date and time of when they hung it. The DON stated the purpose of labeling this information is to determine how long the formula was hung and for infection control. The DON stated failure to label the enteral formula may cause confusion of when it should be discarded and for the resident's safety. During a review of the facility's P&P titled Enteral Feeding - General Policy, last reviewed on 3/2024, the P&P indicated that the enteral formula should be labeled with time, date, resident's name, and nurse's initials when hung. The P&P indicated that the enteral nutrition is provided for those residents who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 461's admission Record (AR), the AR indicated the facility admitted the resident on 11/12/2020, with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. During a review of Resident 461's History and Physical (H&P), dated 1/16/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 461's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. During a review of Resident 461's physician's orders (PO), dated 10/5/2024, the PO indicated an order for: - Cefepime ((a type of medications used to treat bacterial infections in many different parts of the body) 2 gram (gm, a unit of weight) via IV over 30 minutes every (q) 24 hours (hrs) for 3 days (sepsis, a life-threatening medical emergency that occurs when the body has an extreme response to an infection) (start 10/5/2024 at 6 p.m.) - Vancomycin (an antibiotic) in dextrose (sugar solution) 1 gram/200 ml via IV over 120 minutes q 8 hours for 5 days (start at 10 p.m.) (sepsis) (start when available) (first dose today at 2 p.m.) During a review of the Intravenous Therapy Record (a document that records information about the insertion, monitoring, and dressing changes of an IV catheter for the residents) for 10/2024, the record indicated Resident 461 had a peripheral IV line at the left hand. The record indicated the resident was started on Cefepime 2 gm q 12 hrs IV on 10/5/2024 with stop date of 10/8/2024 and Vancomycin 1 gm q 8 hrs IV on 10/5/2024 with stop date of 10/10/2024. During a concurrent observation and interview on 10/22/2024, at 9:39 a.m., with Licensed Vocational Nurse 14 (LVN 14), in Resident 461's room, Resident 461's peripheral IV line at the left hand was not labeled with the date, time, and the initial of the nurse who started/changed the dressing of the peripheral line and the flush port did not have an orange cap. LVN 14 stated the peripheral line should be labeled with the date, time, and initials of the nurse who inserted the peripheral line or changed the dressing and the flush port should have an orange cap to know how old the line was and to prevent infection to the resident. LVN 4 also stated they should have verified with the physician if the peripheral IV was still needed after completion of the IV antibiotics. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated the staff should have placed the date, time, and initial of the nurse who inserted or changed the dressing of the peripheral IV and placed an orange cap on the flush port of the peripheral IV to know how long the line and the dressing was placed and to determine if there is a need to change the IV line or dressing to prevent infection. The DON also stated the staff should verify with MD if the peripheral IV can be discontinued once the IV antibiotic regimen is completed. During a review of the facility's recent policy and procedure (P&P) titled Maintenance of IV Therapy, last reviewed on 1/18/2024, the P&P indicated IV site dressing must be labeled with date, time, and initialed. During a review of the facility's recent policy and procedure (P&P) titled, Peripheral IV: Insertion of a Catheter, last reviewed on 1/18/2024, the P&P indicated to change site every 72 hours and if needed (PRN) for complications. During a review of the facility's recent policy and procedure (P&P) titled Peripheral IV: Removal, last reviewed on 1/18/2024, the P&P indicated IV peripheral catheters shall be removed routinely after 72 hours or length of time extended with physician order. IV catheters shall be removed if there is pain, redness, tenderness or swelling noted at the insertion site. During a review of the facility's recent policy and procedure (P&P) titled SWABCAP (a disinfecting cap for needless connectors), last reviewed on 1/18/2024, the P&P indicated upon completion of IV antibiotic, hydration, or other IV solution, a new Swabcap will be placed onto the Luer lock (a type of fitting that creates a leak-proof connection between two parts, typically a syringe and a needle) connector to disinfect the access site. c. During a review of Resident 462's admission Record (AR), the AR indicated the facility admitted the resident on 9/30/2024, with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. During a review of Resident 462's History and Physical (H&P), dated 10/1/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 462's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and sometimes had the ability to understand others. The MDS indicated the resident had an IV access. During a review of Resident 462's physician orders (PO), the PO indicated an order for: - 9/30/2024 Linezolid (an antibiotic) 600 mg/ 300 ml IVPB (IV piggyback, a method of medication administration commonly used for medical treatments, especially antibiotics). Infuse 300 ml over 60 minutes into the vein q 12 hr. (Pneumonia, an infection of one or both lungs caused by bacteria, viruses, or fungi) for 7 days till 10/8/2024. - 10/14/2024 Give Rocephin (an antibiotic) IV 1 gm for 14 days (for respiratory infection) daily. During a review of Intravenous Therapy Record for 10/2024, the record indicated Resident 462 had a right arm peripheral IV. The record indicated the resident completed Linezolid 600 mg/300 ml IVPB on 10/8/2024 and was started on Rocephin IV 1 gm for 14 days daily. During a concurrent observation and interview on 10/22/2024, at 11:05 a.m., with CNA 2, in Resident 462's room, Resident 462 was lying in bed with right arm peripheral IV not labeled with the date, time, and initials of the nurse who inserted the line or when the last dressing change was done. CNA 2 stated there was no date, time and initial of the nurse on the resident's right arm (RA) peripheral IV and had no orange cap on the flush port. CNA 2 stated she knew the nurses should be labeling the IV lines and the port should be covered with orange cap to prevent infection to the resident. During an interview on 10/25/2024, at 1:55 p.m., with the DON, the DON stated the staff should have placed the date, time, and initial of the nurse who inserted or changed the dressing of the RA peripheral IV and placed an orange cap on the flush port of the RA peripheral IV to know how long the line and the dressing was placed and to determine if there is a need to change the IV line or dressing to prevent infection. The DON also stated the staff should verify with MD if the peripheral IV can be discontinued once the IV antibiotic regimen is completed. During a review of the facility's recent policy and procedure (P&P) titled Maintenance of IV Therapy, last reviewed on 1/18/2024, the P&P indicated IV site dressing must be labeled with date, time, and initialed. During a review of the facility's recent policy and procedure (P&P) titled, Peripheral IV: Insertion of a Catheter, last reviewed on 1/18/2024, the P&P indicated to change site every 72 hours and PRN complications. During a review of the facility's recent policy and procedure (P&P) titled Peripheral IV: Removal, last reviewed on 1/18/2024, the P&P indicated IV peripheral catheters shall be removed routinely after 72 hours or length of time extended with physician order. IV catheters shall be removed if there is pain, redness, tenderness or swelling noted at the insertion site. During a review of the facility's recent policy and procedure (P&P) titled SWABCAP (Disinfecting cap for needless connectors), last reviewed on 1/18/2024, the P&P indicated upon completion of IV antibiotic, hydration, or other IV solution, a new Swabcap will be placed onto the Luer lock connector to disinfect the access site. Based on observation, interview, and record review, the facility failed to administer parenteral (a route outside the digestive system, such as by injection) fluids or medications consistent with professional standards of practice by failing to: 1. Ensure the peripheral intravenous catheter (IV, a thin, flexible tube that is inserted into veins to give treatments including fluids, drugs, or blood transfusions) dressing (clear protective cover placed over the IV catheter insertion site) was labeled per the facility policy for five of eight sampled residents (Resident 97, 81, 45, 461 and 462). 2. Ensure residents with IV catheters had physician orders for IV catheters for three of three sampled residents (Resident 97, 81, and 45 3. Ensure the IV catheter was routinely removed and replaced every 72 hours per facility policy for three of three sampled resident (Resident 97, 81, and 45) 4. Clarify with the primary physician if the peripheral intravenous catheter was still needed post I.V. antibiotic completion for two of five sampled residents (Residents 461 and 462) 5. Place a swab cap/orange cap (an alcohol-containing caps that twist onto I.V. access points for disinfection and protection) on the flush port of the peripheral I.V. for two of five sampled residents (Residents 461 and 462. 6. Ensure the IV catheter site did not have signs and symptoms of infiltration (accidental leakage of the IV solution into the surrounding tissue instead of flowing into the vein) for one of one sampled resident (Resident 45). These deficient practices placed the residents at risk for developing complications such as inflammation of the vein and infection. Findings: a. During a review of Resident 97's admission Record, the admission Record indicated the facility admitted the resident on 12/18/2023 and most recently readmitted the resident on 10/8/2024 with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), dependence on a ventilator (machine that pumps air into patients' airways when they are unable to adequately breathe on their own), tracheostomy (opening surgically created through the front of the neck and into the rachea [windpipe]), and end stage renal disease (a medical condition in which a person's kidneys [organs that remove waste products from the blood and produce urine] stop functioning on a permanent basis) During a review of Resident 97's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/26/2024, the MDS indicated the resident was sometimes able to understand others and sometimes able to make himself understood. The MDS indicated the resident was dependent on staff for toileting, dressing, personal hygiene, bathing, oral hygiene, and mobility. During a review of Resident 97's physician's orders, the physician's orders indicated the following: - Tigecycline (an antibiotic, a medication that treats bacterial infections) 50 milligrams (mg, a unit of measurement) via IV every 12 hours for 38 days until 11/15/2024 for osteomyelitis (inflammation of bone or bone marrow, usually due to infection), dated 10/8/2024. - Meropenem (an antibiotic) 500 mg via IV twice a day for 38 days, for osteomyelitis, dated 10/8/2024. - Amikacin sulfate (an antibiotic) 375 mg via IV every day after hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), (Monday, Wednesday, and Friday) until 11/15/2024, dated 10/8/2024. During a review of Resident 97's Care Plan (CP) titled, Alteration in health status related to osteomyelitis, requires IV, ., antibiotic treatment, ., at risk for infection and or infiltration related to presence of saline lock (IV) initiated 10/9/2024, the CP indicated to follow the facility's protocol for IV site maintenance. During a review of Resident 97's Nurses' admission Record, dated 10/8/2024, the admission record indicated the resident had a right inner forearm IV site upon admission. During a concurrent observation and interview on 10/22/2024 at 10:52 a.m., with Licensed Vocation Nurse 1 (LVN 1), in Resident 97's room, LVN 1 stated the resident was receiving IV antibiotics, but she did not administer them. LVN 1 stated the registered nurses administer Resident 97's IV medication. LVN 1 unwrapped Resident 97's bandage on the right forearm, observed an IV catheter inserted in the right inner forearm covered with a clear dressing. LVN 1 stated the IV dressing was not labeled with a date. LVN 1 stated she thought the IV dressing should be dated, but she wasn't sure. During a concurrent interview and record review on 10/23/2024 at 3:45 p.m., with Registered Nurse 2 (RN 2), Resident 97's Intravenous Therapy Record - Peripheral Catheter log for 10/2024 was reviewed. RN 2 stated Resident 97 was readmitted from the hospital on [DATE] with an IV. RN 2 stated IVs are usually changed every seven days. RN 2 stated the dressing covering the IV should always be labeled with the date and time of the IV catheter insertion and the initials of the nurse that inserted the IV, but Resident 97's dressing was not labeled. RN 2 stated when IVs are removed, changed, or inserted there should be documentation in the IV log. RN 2 stated there was no documented evidence that Resident 97's IV was changed after his readmission on [DATE]. During a concurrent interview and record review on 10/23/2024 at 3:50 p.m. with Registered Nurse 1 (RN 1), Resident 97's Nurses' admission Record, dated 10/8/2024 was reviewed and RN 1 stated the admission record indicated Resident 97 was readmitted from the hospital with an IV in the right inner forearm. RN 1 stated she could not remember how often IV sites should be changed, but she thought it was every three or seven days. RN 1 stated the Director of Nursing (DON) would be able to answer how often IVs should be changed. During an interview on 10/23/2024 at 4 p.m. with the DON, the DON stated she did not remember how often IV catheters should be changed. The DON stated the facility does not routinely change resident IVs, but they are changed when they are infiltrated. The DON stated peripheral IV dressings should be labeled with the date. During an interview and record review on 10/23/2024 at 4:10 p.m., with DON, the facility procedures regarding peripheral IVs were reviewed. The DON stated the procedure indicated that all peripheral IV sites require a physician's order, are to be changed every 72 hours, require a physician's order to keep the IV site for longer than three days, and should be labeled with the date and time of insertion. The DON stated Resident 97's peripheral IV dressing was not labeled and was not changed per the facility procedure. During a concurrent an interview and record review on 10/23/2024 at 4:15 p.m. with RN 1, Resident 97's physician orders were reviewed. RN 1 stated she had cared for Resident 97 since his readmission on [DATE] and the IV site was not changed since his readmission. RN 1 stated Resident 97's IV site was not changed since his readmission because there was no physician's order regarding the peripheral IV site maintenance, but there should have been. RN 1 stated IVs should be changed to prevent infection in the resident. During an interview on 10/25/2024 at 10 a.m. with the Infection Preventionist (IP), the IP stated the IV catheter dressing should be labeled with the date the IV was last changed because the facility policy indicated IV catheter sites are changed every 72 hours. The IP stated IV sites are changed to prevent infections from an indwelling device. The IP stated when an indwelling peripheral catheter is not routinely changed there is the potential for the IV catheter to introduce microorganisms into the blood stream causing sepsis (a life-threatening blood infection) in residents. During a review of the facility policy and procedure titled, Maintenance of IV Therapy, last reviewed 3/2024, it indicated the purpose of the policy is to provide a guideline on the maintenance of an IV. Licensed nurses will follow the guidelines set forth by the facility on IV infusions and maintenance. IV site dressings must be labeled with date, time, and initialed. Dressing must be assessed each shift and documented. During a review of the facility procedure titled, Peripheral IV: insertion of a catheter, undated, the procedure indicated the procedure's purpose was to provide a venous access for the administration of fluids, medications and/or blood and blood products continuously. Verify a physician's order for an IV catheter. Change the site every 72 hours and as needed if complications. Residents with poor venous access may extend IV site changes with a physician's order and if no signs or symptoms of complications are present. Monitor and document each shift. A review of the facility procedure titled, Peripheral IV: removal, undated, the procedure indicated IV peripheral catheters shall be removed routinely after 72 hours or length of time extended with physician order. d. During a review of Resident 81's admission Record indicated the facility admitted the resident on 3/25/2023 and readmitted in the facility on 8/19/2024 with diagnoses including chronic respiratory failure, tracheostomy, and type diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 81's History and Physical (H&P) dated 4/22/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 81's physician orders, the physician orders indicated the following: - 10/14/2024: Ccefepime one (1) gram IV every 24 hours for seven (7) days for pneumonia (an infection/inflammation in the lungs). During a concurrent observation and interview on 10/22/2024 at 12:16 p.m. with the Director of Staff Development (DSD), in Resident 81's room Resident 81 had a peripheral IV on the right hand (RH) with a transparent dressing and not labeled with the date and initials of the licensed nurse (LN) who inserted the peripheral IV. The DSD stated the peripheral IV should be labeled with the date and initials of the LN who inserted the peripheral IV so they would know when to change the IV site and prevent infection. During a concurrent observation, interview and record review on 10/22/2024 at 12:24 p.m., with Registered Nurse 3 (RN 3), inside Resident 81's room, Resident 81 had a peripheral IV on the right hand (RH) with a transparent dressing and not labeled with the date and initials of the licensed nurse (LN) who inserted the peripheral IV. Resident 81's physician's orders dated 10/14/2024 and IV Therapy Record - Peripheral Catheter were reviewed. RN 3 verified Resident 81's peripheral IV on the RH did not indicate the insertion date and initials of the LN. RN 3 verified Resident 81 had an order for cefepime IV every 24 hours for pneumonia. RN 3 stated the LN do not change peripheral IV catheters if there are no signs and symptoms of infiltration such as redness, swelling, tenderness, and leak around the insertion site. RN 3 verified there was no physician's order to insert peripheral IV catheter and maintenance of IV site such as monitoring of site every shift, flushing with normal saline NS - a saltwater solution), before and after administration of medication, and saline flush maintenance every shift. RN 3 verified the IV Therapy Record did not indicate when the peripheral IV catheter was started and was unable to tell the exact date the peripheral IV was inserted. RN 3 stated the LNs follow the IV Therapy Record provided by the pharmacy for peripheral IV maintenance. RN 3 stated there should have been a physician's order for peripheral IV catheter insertion, monitoring of peripheral IV site, and maintenance of peripheral IV catheter every shift, and the transparent dressing should have been labeled with the date the peripheral IV catheter was inserted and LN initials as it placed the resident at risk for developing complications and infection. During a concurrent interview and record review on 10/25/2024 at 7:15 a.m. with Registered Nurse 9 (RN 9) Resident 81's IV Therapy Record and the facility policy and procedure (P&P) titled, IV Therapy Dressing and Tubing Care, Peripheral IV: Insertion of a Catheter, Peripheral IV: Conversion to a Saline Lock, were reviewed. RN 9 stated upon receipt of an order from the physician for an IV therapy, the RN receiving the order will write the order for the medication and send to the pharmacy. RN 9 stated they do not enter a physician's order to insert a peripheral IV catheter and maintenance of peripheral IV. RN 9 further stated the RNs utilize the IV Therapy Record provided by the pharmacy for peripheral IV catheter maintenance which includes site check every shift, saline lock flush before and after medication administration, date inserted, and dressing changes. RN 9 stated she monitors the peripheral IV site by flushing the catheter with NS and if there is resistance when flushing the catheter, then they change the peripheral IV catheter site. RN 9 stated if a peripheral IV was wrapped, she does not open or unwrap and check the insertion site for signs and symptoms of infiltration. RN 9 stated if a peripheral IV catheter is covered, she should have removed the wrap and check the insertion site to make there are no signs of infection. RN 9 stated the facility should have obtained a physician's order to insert peripheral IV catheter and maintenance of peripheral IV site per facility P&P as it placed the resident at risk for developing infection from the catheter insertion site. During a concurrent interview and record review on 10/25/2024 at 9:30 a.m. with the Director of Nursing (DON) the facility policy and procedure (P&P) titled, IV Therapy Dressing and Tubing Care, Peripheral IV: Insertion of a Catheter, Peripheral IV: Conversion to a Saline Lock were reviewed. The DON stated facility practice is to change dressing for the peripheral IV catheter but do not change the peripheral IV catheter site. The DON verified the facility P&P indicated to change site every 72 hours and as needed for complications. The DON stated the staff should have placed the date, time, and initial of the nurse who inserted or changed the dressing of the peripheral IV for the staff to be aware when the peripheral IV was inserted and determine when the next site change is to prevent infection. The DON stated a physician's order should have been obtained to insert peripheral IV catheter and IV maintenance. During a review of the facility's P&P titled, IV Therapy Dressing and Tubing Care, last reviewed 1/18/2024, the P&P indicated: - IV site, tubing, dressing shall be assessed once per shift by an RN. - Dressing should be dated, timed, and be initialed when completed. - Dressing change should be documented. During a review of the facility's P&P titled, Peripheral IV: Insertion of a Catheter, last reviewed 1/18/2024, the P&P indicated: - Change site every 72 hours and as needed complications. - A physician's order is needed to start any IV. - Label site with date, time. Gauge, and length of catheter or needle and initials. During a review of the facility's P&P titled, Conversion to a Saline Lock, last reviewed 1/18/2024, the P&P indicated: - Change site every 72 hours and as needed complications. - Document date and time. - Monitor and document condition of site every shift. - Label site with date, time, gauge, and length of catheter or needle and initials of person performing the procedure. e. During a review of Resident 45's admission Record indicated the facility admitted the resident on 5/17/2024 and readmitted in the facility on 8/25/2024 with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy (a surgical opening fitted with a device to allow feedings to administered directly to the stomach common for people with swallowing problems). During a review of Resident 45's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 45's physician orders, the physician orders indicated the following: -10/13/2024: Cefepime one (1) gram IV one (1) dose now. Staring 10/14/2024, give cefepime 500 mg via IV every 24 hours until 10/19/2024. During a concurrent observation and interview on 10/22/2024 at 12:37 p.m. with the Director of Staff Development (DSD), in Resident 45's room, Resident 45's left forearm (LFA) was wrapped with a blue colored elastic wrap. The DSD removed the blue elastic wrap and observed a peripheral IV catheter covered with transparent dressing with dried blood on the surrounding area of the insertion site and not labeled with the date and initials of the licensed nurse (LN) who inserted the peripheral IV. The DSD stated the peripheral IV should be labeled with the date and initials of the LN who inserted the peripheral IV so they would know when to change the IV site and prevent infection. During a concurrent observation, interview and record review on 10/22/2024 at 12:54 p.m. with Registered Nurse 3 (RN 3), in Resident 45's room, Resident 45's physician's order and IV Therapy Record - Peripheral Catheter records were reviewed. RN 3 verified Resident 45's peripheral IV on the LFA did not indicate the insertion date and initials of the staff. RN 3 verified Resident 45 had an order for cefepime IV every 24 hours. RN 3 stated the staff do not change peripheral IV catheters if there are no signs and symptoms of infiltration such as redness, swelling, tenderness, and leak around the insertion site. RN 3 verified there was no physician's order to insert peripheral IV catheter and maintenance of IV site such as monitoring of site every shift, flushing with normal saline NS - a saltwater solution), before and after administration of medication, and saline flush maintenance every shift. RN 3 verified the IV Therapy Record did not indicate when the peripheral IV catheter was started and was unable to tell the exact date the peripheral IV was inserted. RN 3 stated the staff follow the IV Therapy Record provided by the pharmacy for peripheral IV maintenance. RN 3 stated there should have been a physician's order for peripheral IV catheter insertion, monitoring of peripheral IV site, and maintenance of peripheral IV catheter every shift, and the transparent dressing should have been labeled with the date the peripheral IV catheter was inserted and LN initials as it placed the resident at risk for developing complications and infection. During a concurrent interview and record review on 10/25/2024 at 7:15 a.m. with Registered Nurse 9 (RN 9), Resident 45's IV Therapy Record and the facility policy and procedure (P&P) titled, IV Therapy Dressing and Tubing Care, Peripheral IV: Insertion of a Catheter, Peripheral IV: Conversion to a Saline Lock, were reviewed. RN 9 stated upon receipt of an order from the physician for an IV therapy, the RN receiving the order will write the order for the medication and send to the pharmacy. RN 9 stated they do not enter a physician's order to insert a peripheral IV catheter and maintenance of peripheral IV. RN 9 further stated the RNs utilize the IV Therapy Record provided by the pharmacy for peripheral IV catheter maintenance which includes site check every shift, saline lock flush before and after medication administration, date inserted, and dressing changes. RN 9 stated she monitors the peripheral IV site by flushing the catheter with NS and if there is resistance when flushing the catheter, then they change the peripheral IV catheter site. RN 9 stated if a peripheral IV was wrapped, she does not open or unwrap and check the insertion site for signs and symptoms of infiltration. RN 9 stated if a peripheral IV catheter is covered, she should have removed the wrap and check the insertion site to make there are no signs of infection. RN 9 stated the facility should have obtained a physician's order to insert peripheral IV catheter and maintenance of peripheral IV site per facility P&P as it placed the resident at risk for developing infection from the catheter insertion site. During a concurrent interview and record review on 10/25/2024 at 9:30 a.m. with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, IV Therapy Dressing and Tubing Care, Peripheral IV: Insertion of a Catheter, Peripheral IV: Conversion to a Saline Lock, were reviewed. The DON stated facility practice is to change dressing for the peripheral IV catheter but do not change the peripheral IV catheter site. The DON stated that if a peripheral IV was covered with a wrap, the staff were supposed to remove the wrap and check the insertion site for any signs and symptoms of infiltration. The DON stated the presence of dried blood under dressing The DON verified the facility P&P indicated to change site every 72 hours and as needed for complications. The DON stated the staff should have placed the date, time, and initial of the nurse who inserted or changed the dressing of the peripheral IV for the staff to be aware when the peripheral IV was inserted and determine when the next site change is to prevent infection. The DON stated a physician's order should have been obtained to insert peripheral IV catheter and IV maintenance. During a review of the facility's P&P titled, IV Therapy Dressing and Tubing Care, last reviewed 1/18/2024, the P&P indicated: - IV site, tubing, dressing shall be assessed once per shift by an RN. - Dressing should be dated, timed, and be initialed when completed. - Dressing change should be documented. During a review of the facility's P&P titled, Peripheral IV: Insertion of a Catheter, last reviewed 1/18/2024, the P&P indicated: - Change site every 72 hours and as needed complications. - A physician's order is needed to start any IV. - Label site with date, time. Gauge, and length of catheter or needle and initials. During a review of the facility's P&P titled, Conversion to a Saline Lock, last reviewed 1/18/2024, the P&P indicated: - Change site every 72 hours and as needed complications. - Document date and time. - Monitor and document condition of site every shift. - Label site with date, time, gauge, and length of catheter or needle and initials of person performing the procedure.

Based on observation, interview, and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for adult residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services. This deficient practice had the potential for 70 adult subacute residents with physician's orders for daily RNA to experience a decline in range of motion (ROM, full movement potential of a joint), mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting) function. Cross reference F842 Findings: During a review of the active physician's orders for residents on RNA services dated 10/23/24 indicated 70 adult subacute residents with physician's orders for RNA to provide treatments and services including but not limited to, ROM exercises to upper extremities (UE, shoulder, elbow, wrist, hand) and lower extremities (LE, hip, knee, ankle, foot), application of splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) or braces (an external device to support, align, or correct a movable part of the body), and ambulation (walking). During a review of the facility's September 2024 Adult Daily Assignment Sheet for Certified Nursing Assistants sign-in indicated the following RNA staff assignments for the 7:00 a.m. to 3:30 p.m. shift: -9/1/2024: one (1) RNA -9/2/2024: 1 RNA -9/3/2024: two (2) RNAs -9/4/2024: 2 RNAs -9/5/2024: 2 RNAs -9/6/2024: 2 RNAs -9/7/2024: 2 RNAs -9/8/2024: 1 RNA -9/9/2024: 2 RNAs -9/10/2024: 2 RNAs -9/11/2024: 2 RNAs -9/12/2024: 2 RNAs -9/13/2024: 2 RNAs -9/14/2024: 2 RNAs -9/15/2024: 1 RNA -9/16/2024: 2 RNAs -9/17/2024: 2 RNAs -9/18/2024: 2 RNAs -9/19/2024: 1 RNA -9/20/2024: 2 RNAs -9/21/2024: 1 RNAs -9/22/2024: 1 RNA -9/23/2024: 2 RNAs -9/24/2024: 2 RNAs -9/25/2024: 2 RNAs -9/26/2024: 2 RNAs -9/27/2024: 1 RNA -9/28/2024: 1 RNA -9/29/2024: 1 RNA -9/30/2024: 2 RNAs During a review of the facility's October 2024 Adult Daily Assignment Sheet for Certified Nursing Assistants sign-in indicated the following RNA staff assignments for the 7:00 a.m. to 3:30 p.m. shift: -10/1/2024: 2 RNAs -10/2/2024: 1 RNA -10/3/2024: 2 RNAs -10/4/2024: 2 RNAs -10/5/2024: 2 RNAs -10/6/2024: 1 RNA -10/7/2024: 2 RNAs -10/8/2024: 2 RNAs -10/9/2024: 2 RNAs -10/10/2024: 2 RNAs -10/11/2024: 2 RNAs -10/12/2024: 2 RNAs -10/13/2024: 1 RNA -10/14/2024: 2 RNAs -10/15/2024: 2 RNAs -10/16/2024: 2 RNAs -10/17/2024: 2 RNAs -10/18/2024: 2 RNAs -10/19/2024: 1 RNA -10/20/2024: 2 RNAs -10/21/2024: 2 RNAs -10/22/2024: 2 RNAs During an interview on 10/23/2024 at 8:06 a.m., Restorative Nursing Aide (RNA 1) and Restorative Nursing Aide (RNA 2) stated there were only 2 RNAs scheduled today. RNA 1 stated there were residents on RNA that required 2 RNAs to complete the treatments such as walking and sitting a resident at the edge of the bed. RNA 1 and RNA 2 stated they tried to see as many residents as possible in one day, but they could not complete all the RNA treatments for every resident each day. RNA 1 and RNA 2 stated they see about 18-20 residents a day for RNA. During an RNA treatment observation of Resident 15 and interview on 10/23/2024 at 10:16 a.m., with RNA 1, the RNA treatment session started at 10:16 a.m. and ended at 10:53 a.m. (37 minutes). RNA 1 stated the RNA treatment session usually took about 30 minutes to complete for PROM for both UE and LE extremities and for splints on both hands. RNA 1 stated the RNAs also assisted with feeding for a couple of residents. RNA 1 stated the RNAs could not get to everyone every day on RNA. During an interview on 10/23/2024 at 1:16 p.m. with RNA 1 and RNA 2, RNA 1 stated sometimes there was just 1 RNA and we never have more than 2 RNAs in one day. RNA 1 and RNA 2 stated there were too many residents on RNA for the RNAs to complete the RNA treatments for every resident. During a concurrent interview and record review of the facility's September and October 2024 Adult Daily Assignment Sheet for Certified Nursing Assistants sign-in, with the Director of Staffing Development (DSD), the DSD confirmed during September and October 2024, there were only 1 or 2 RNAs assigned each day. The DSD stated RNA treatments were supposed to be about 15 minutes per resident, but some residents required more time because they were more contracted (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and some residents required two RNAs to complete the treatment such as sitting at bedside or ambulation. The DSD stated 2 RNAs were not enough to see all the residents with RNA orders. During an interview on 10/23/2024 at 4:22 p.m., the Director of Nursing (DON), the DON stated all residents with RNA orders should be seen for RNA treatments as ordered. The DON stated if residents with order for RNA did not receive their RNA treatments, then the residents' muscles could be tighter, could lead to more contractures and stiffness and cause another care problem because the facility was not completing the RNA orders such as ambulation or exercises. During a review of the facility's policy and procedure reviewed 4/2024, titled, Restorative Nursing Services, indicated residents will receive restorative nursing care as needed. Restorative nursing services personnel are assigned based on the individual residents' plan of care.

Based on observation, interview and record review, the facility failed to: 1. Have an available supply of simethicone (a medication used to treat symptoms of gas such as painful pressure, fullness, and bloating) and renal multivitamin (a multivitamin designed for dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed] patients to replace the vitamins lost during dialysis) in the medication carts affecting 1 of 5 observed residents (Resident 106) during the medication administration task. As a result, Resident 106 did not receive simethicone and renal multivitamin on 10/22/24 at 10 a.m. 2. Dispose (remove, destroy) of controlled drugs ([CD]- medications which have a potential for abuse and may also lead to physical or psychological dependence]) within 90 days of order for discontinuation, for 6 of 12 sampled CDs in the Director of Nursing's (DON's) office observed during the medication storage task. As a result, the facility did not follow the state and federal regulations for control and accountability of CD's. These failures had the potential to cause Resident 44 to experience health complications such as vitamin deficiency and worsening gas resulting in the health and well-being of Resident 44 being negatively impacted, and increased the opportunity for CD diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use) and the potential for accidental exposure to harmful medications to all residents, possibly leading to physical and psychosocial harm and hospitalization. Cross referenced with F759 Findings: During a review of Resident 106's admission Record a document containing demographic and diagnostic information,) [undated,] the admission Record indicated the facility admitted Resident 106 on 9/19/24 with diagnoses including end stage renal disease (irreversible kidney failure,) renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed,) constipation. During an observation on 10/22/24 at 10 a.m. in Medication Cart 9, Licensed Vocational Nurse (LVN) 11 was observed administering vitamin D, baclofen (medication used for muscle tightness,) minoxidil (a medication used for high blood pressure,) Floranex (a medication used for digestion) via gastrostomy tube ([G-tube] - a tube inserted through the belly that brings nutrition directly to the stomach) followed by administering artificial tears in each eye to Resident 106, and was observed not administering simethicone and renal multivitamin to Resident 106 via G-tube. During a review of Resident 106's Physician Orders (a report listing the physician order for the resident,) from 10/1/24 to 10/31/24, the Physician's Order indicated Resident 106 was prescribed: 1. Simethicone 80 mg tablet via G-tube three times a day for abdominal distention (swelling,) starting 9/19/24, 2. Renal multivita.m.in one (1) tablet via G-tube daily for supplement, starting 9/19/24. During a review of Resident 106's clinical record including physician orders, progress notes and nurse's notes, the clinical record did not contain documentation that Resident 106 should not be administered the above medications on 10/22/24. During a review and concurrent interview with LVN 13 of Resident 106's ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for October 2024, the MAR indicated Resident 106's: 1. Simethicone 80 mg tablet via G-tube three (3) times a day, at 9 p.m., 1 p.m. and 5 p.m. 2. Renal multivitamin one (1) tablet via G-tube daily, at 9 a.m. The MAR indicated the 9 a.m. doses for simethicone 80 mg and renal multivitamin were circled with the initials of LVN 13. LVN 13 stated that a circle with LVN initials on the MAR indicated that the medication was not administered. During an interview on 10/22/24 at 10:10 a.m. with LVN 11, LVN 11 stated that LVN 11 did not administer simethicone 80 milligram ([mg] - a unit of measure of mass) tablet and renal multivitamin tablet to Resident 106 during the morning medication administration at 10 a.m. to Resident 106, as prescribed by Resident 106's physician, since both medications were not available in the medication cart. LVN 11 stated that these mediations were not available in the Medication Room either and that LVN 11 did not have access to the Central Supply Room (a room that stores additional stock of house supply [not resident specific] medications) to check for availability. LVN 11 stated that usually a Central Supply Employee (CSE) would make rounds daily before the morning medication administration time to replenish medications, however LVN 11 had not seen that individual that morning (10/22/24.) LVN 11 stated that medications should be readily available to ensure timely administration at the scheduled times. LVN 11 stated it was important to receive these medications as ordered by the physician, and missing doses of these medications can harm Resident 106 by causing worsening uncomfortable gas and vitamin deficiency. During an interview on 10/22/24 at 10:20 a.m. with Registered Nurse (RN) 3, RN 3 that the Central Supply Room had stock of medications, but licensed nursing staff did not have access to that room. During an observation and concurrent interview in Central Supply Room, on 10/22/24 at 10:30 a.m. with Central Supply Employee (CSE) 1, the room contained several renal multivitamin medication bottles stored on the shelf and no bottles of simethicone were found. The CSE 1 stated that the Director of CS (DCS) was not currently in the facility and had gone to the off-site warehouse to bring simethicone since there were none available in the Medication Room and Central Supply Room. CSE 1 stated that only CSEs had access to the Central Supply Room and that licensed nurses were unable to access the room. During an interview on 10/22/24 at 10:42 a.m. with the DON, the DON stated that licensed nurses were able to obtain medications from the Medication Room and did not have access to the medications stored in the Central Supply Room. The DON stated that licensed nurses needed to have access to medications throughout the facility and not rely on CSEs to ensure timely administration of medications to residents. The DON stated that medications should be administered within a 60-minute window from the time scheduled and that medications administered after that were considered late and a medication error. The DON stated that there should be no reason why licensed nurses should not have access to medications in the facility and no reason for them to wait for CSEs to grant access to the medications. The DON stated that as a result simethicone and renal multivitamin were not administered at the scheduled time at 9 a.m. on 10/22/24 to Resident 106. During an interview on 10/22/24 at 10:56 a.m., with the Director of Central Supply (DCS) and in the presence of DON, the DCS stated that simethicone was not available in the facility that day (10/22/24) and that DCS had gone to the off-site warehouse to obtain a supply. The DCS stated that licensed nurses did not have access to the Central Supply Room. The DCS stated that licensed nurses not having access to Central Supply Room and relying on CSEs daily rounds to replenish stock had caused the unavailability of medications in the medication carts and late administration of simethicone and renal multivitamin to Resident 106 that day (10/22/24.) The DCS stated that the current process was not efficient and not in the best interest of the residents in ensuring they receive medications at the scheduled times. The DON stated that the process was failing and there needed to be a change to always make medications more accessible to licensed nurses. During an observation, interview and record review on 10/22/24 at 1:40 p.m. in the DON's office, with the DON, six (6) CD's awaiting final disposition (process of destroying unused medications) were found in a locked cabinet with the CD accountability records signed and dated on 1/9/2024, 2/17,2024, 2/26/2024, 5/4/2024, 6/10/2024, 7/16/2024. The DON stated the Consultant Pharmacist (CP) comes once a month to dispose of the CD in the DON's presence, and the CDs were last disposed on 10/14/24 with the CP. The DON stated according to state and federal regulations CDs should be destroyed within 90 days of order for discontinuation or resident discharge. The DON stated the facility failed to dispose of six (6) CDs dated 1/9/2024, 2/17,2024, 2/26/2024, 5/4/2024, 6/10/2024, 7/16/2024 within 90 days of order for discontinuation or resident discharge. The DON stated the DON understood the importance of CD accountability to prevent diversions and accidental exposure of harmful substances to residents. During a review of the facility's policy and procedures (P&P), titled Medication Pass, last revised May 2023, the P&P indicated The purpose of this policy is to provide a guideline on how to properly complete a Medication Pass. Procedures 1. Follow the 10 Patient Rights of giving medications. 3. Check medications against the MAR to be correct. 5. Give medications as ordered. General Reminders 1. You have 1 hour before and 1 hour after the administered time to complete medication pass. During a review of the facility's P&P, titled Medication Pass Via Gtube/Jtube, last revised May 2020, the P&P indicated The purpose of this policy is to provide a guideline on how to pass medications through the Gastrostomy/Jejunostomy Tube. 7. Follow the 10 Patient Rights of giving medications. During a review of the facility's P&P, titled Medication Administration Techniques, last revised 10/25/23, the P&P indicated: Prior to passing meds 5. Start pass in a timely manner: time allotted for pass is two hours, one hour before to one hour after the scheduled administration time. 6. Observe 10 Medication Rights: 5. Right Time During the pass 3. Dispense/prepare medications as per M.D. (Medical Doctor/physician) orders. During a review of the facility's P&P, titled 10 Medication Rights, last revised July 2022, the P&P indicated The purpose of this policy is to provide current guidelines for Medication Patient Rights. 5. Right Time - Administering medications at a time that was intended by the prescriber. During a review of the facility's P&P, titled Medication Error Policy and Record Completion, last revised March 2024, the P&P indicated A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm or no harm while the medication is in control of the health care professional. Types of Medication Errors 4. Administration Error - Types of administration errors include: wrong patient, dose, time, medication route, rate, omission, and unauthorized dose given. During a review of the facility's P&P, titled Disposal of Medications, last revised 4/2024, the P&P indicated that Controlled Drugs labeled as Schedule II, III, IV, and V by the US Drug Enforcement Agency shall be disposed of in the presence of a Registered Nurse (RN) and a registered pharmacist at minimum every 90 days. During a review of the facility's P&P, titled Handling Discontinued Drugs, dated 10/2018, the P&P indicated that When a drug is discontinued it shall be disposed of as soon as possible unless there is a reason to be reused in which case the drug may be held for a maximum of 90 days.

b. During a review of Resident 104's admission Record (AR), the AR indicated the facility admitted the resident on 7/3/2024, and readmitted the resident on 8/26/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), dependence on respirator (a mechanical device that helps a patient breathe by moving air into and out of their lungs), and major depressive disorder (a mental health condition that involves a depressed mood and loss of interest in activities for a significant amount of time). During a review of Resident 104's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/14/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class antidepressant (a prescription medication used to treat depression and other mental health conditions) medication. During a review of Resident 104's physician orders (PO), the PO indicated an order for: 8/26/2024: Monitor episodes of depression manifested by expression of sadness q shift using hash marks for episodes and 0 for none. 10/9/2024: Sertraline 25 milligrams (mg, a unit of weight) tab, take 2 tablets (50 mg) via gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) daily (qd) for depression manifested by expression of sadness, informed consent verified with MD for (X) 6 mos. until 4/9/2025 then re-evaluate. The PO did not indicate there was an order to monitor adverse effects on the use of Sertraline. During a concurrent interview and record review on 10/24/2024, at 10:19 a.m. with Registered Nurse 2 (RN 2), Resident 104's physician orders and Medication Administration Record (MAR) were reviewed. RN 2 stated there was an order for Sertraline 25 mg via g-tube twice a day however, she cannot find an order for monitoring for the adverse effects of its use. RN 2 also stated she cannot find any monitoring for adverse effects of Sertraline use on the MAR. RN 2 stated it is important to monitor for adverse effect of Sertraline to make sure the resident is not having any reaction to the medication. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated the staff should monitor for adverse effect of the antidepressant medications to ensure side effects/ adverse effects were reported to the physician on a timely manner, so the effect are dealt with and resolved. The DON stated it serves as a basis for reduction in dosage or even discontinuation. During a review of the facility's recent policy and procedure (P&P) titled, Medication Regimen Review, last reviewed on 1/18/2024, the P&P indicated a drug regimen review will include medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potentially clinically significant medication adverse consequences. Based on interview and record review the facility failed to ensure the entire medication regimen of the resident was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being by failing to: 1. Monitor for adverse effects (a harmful or abnormal result) for the use of Remeron (a type of antidepressant, a medication used to treat depression [a mental condition that can affect how a person feels, thinks, and acts]) for one out of five sampled residents (Resident 50) 2. Monitor for adverse effects for the use of Buspar (a type of medication primarily used to treat generalized anxiety disorder (a mental health condition that involves excessive and persistent feelings of fear, dread, and uneasiness) for one of five sampled residents (Resident 50) 3. Complete the informed consent (the process where a resident or the resident representative receives information a medical procedure or explaining the risks, benefits, and alternatives) for the use of Remeron and Buspar with the dose, frequency, and indication for one of five sampled residents (Resident 50 4. Monitor for adverse effects on the use of Sertraline, an antidepressant medication used to treat major depressive disorder [a serious mental illness that can affect how a person feels, thinks, and acts) for 1 of 1 sampled resident (Resident 104 These deficient practices violated the rights of the resident to be informed about the medication used for treatment and had the potential to result in the use of unnecessary psychotropic drugs and adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) of the medication. Findings: a. During a review of Resident 50's admission Record (AR), the AR indicated the facility admitted the resident on 3/30/2017 with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), gastrostomy tube (G-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), anxiety disorder, and major depressive disorder (a mental health condition that involves a depressed mood and loss of interest in activities for a significant amount of time). During a review of Resident 50's History and Physical (H&P) dated 3/27/2024, the H&P indicated Resident 50 did not have the capacity to understand and make decisions. During a review of Resident 50's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/27/2024, the MDS indicated Resident 50 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 50 was on high-risk drug class antidepressant and antianxiety medications. During a review of Resident 50's physician orders (PO), the PO indicated the following order: -8/7/2024: Buspar 10 mg via G-tube 2 times a day for anxiety manifested by agitation and verbally abusive episodes for 6 months (evaluated by physician and nurse practitioner (NP - a registered nurse with advanced training who can perform many of the same duties as a doctor). -8/7/2024: Remeron 7.5 mg via G-tube at HS for depression manifested by poor appetite for 6 months (evaluation done by physician and NP). During a review of Resident 50's informed consents forms that were obtained by the physician from the responsible party, the forms did not indicate the dosage, frequency, and indication for the use of Remeron and Buspar. During a concurrent interview and record review on 10/24/2024 at 2:51 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 50's physician orders and informed consent forms were reviewed. The MDSC stated upon receipt of physician's order for antidepressant or antianxiety medication, the nurses should also obtain an order for monitoring of adverse effects. The MDSC stated the informed consent should indicate the medication dosage, frequency, and indication for the use of the medication. The MSDC verified there was no physician's order to monitor for adverse effects for the use of Remeron and Buspar. The MDSC verified the informed consent did not indicate the medication dosage, frequency, and indication for the use of Remeron and Buspar. The MDSC stated there should have been an order for the monitoring of adverse effects for the use of Remeron and Buspar to ensure Resident 50 was not having reactions with the use of the medications. The MDSC stated the informed consent should have been completed by the physician including the medication dosage, frequency, and indication for the use of Remeron and Buspar to ensure the resident and/or responsible party understands the risks and benefits as well as the number of medications the resident will be receiving. During an interview on 10/25/2024 3;00 p.m. with the Director of Nursing (DON), the DON stated the staff should monitor for adverse effects of the antidepressant and antianxiety medications to ensure the adverse effects were reported to the physician in a timely manner, so the effects will be addressed timely and possibly resolved. The DON stated it serves as a basis for the reduction in dosage or even discontinuation. The DON stated the informed consent should have been clarified by the nurse from the physician and should be complete to indicate the name of the medication, dosage, frequency, and the indication for use to ensure the resident and/or responsible party understands and aware of the risks and benefits and the amount of medications the resident will be receiving. During a review of the facility's policy and procedure (P&P) titled, Informed Consent for Psychotropic Medications, last reviewed 1/18/2024, the P&P indicated the policy is to establish that a resident or responsible party understands and accepts treatment(s) ordered by their physician. The P&P indicated the following: -The risks and benefits. Dosage, and side effects of restraints and psychotropic medications will be discussed with the resident or responsible party by their physician or NP. -All consents will be maintained in the patient's medical record. During a review of the facility's P&P titled, Medication Regimen Review, last reviewed on 1/18/2024, the P&P indicated a drug regimen review will include medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potentially clinically significant medication adverse consequences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate below 5 percent (%) by having three (3) medication errors out of 33 opportunities contributing to an overall error rate of 9.09% for two (2) out of five (5) sampled residents (Resident 44 and 106) observed during the Medication Administration facility task. The medication errors were due to unavailability of two (2) medications resulting in not administering doses at the scheduled administration times and overlooking to administer one (1) medication at the scheduled time. The medication errors were as follows: 1. Resident 44 did not receive labetalol (a medication used to for hypertension [a condition in which the blood vessels have persistently raised pressure]) at the scheduled time as ordered by Resident 44's physician, and 2. Resident 106 did not receive simethicone (a medication used to treat symptoms of gas such as painful pressure, fullness, and bloating) and Renal multivitamin (a multivitamin designed for dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed] patients to replace the vitamins lost during dialysis) at the scheduled time as ordered by Resident 106's physician. These failures had the potential to cause Resident 44 and 106 to experience health complication such elevated high blood pressure and heart rate, vita.m.in deficiency and worsening gas resulting in the health and well-being of Resident 44 and 106 being negatively impacted. Cross reference with F755 Findings: During an observation on 10/22/24 at 10 a.m. in Medication Cart 9, Licensed Vocational Nurse (LVN) 11 was observed administering vitamin D, baclofen (medication used for muscle tightness,) minoxidil (a medication used for high blood pressure,) Floranex (a medication used for digestion) via gastrostomy tube ([G-tube] - a tube inserted through the belly that brings nutrition directly to the stomach) followed by administering artificial tears in each eye to Resident 106, and was observed not administering simethicone and renal multivitamin to Resident 106 via G-tube. During an interview on 10/22/24 at 10:10 a.m. with LVN 11, LVN 11 stated that LVN 11 did not administer simethicone 80 milligram ([mg] - a unit of measure of mass) tablet and renal multivitamin tablet to Resident 106 during the morning medication administration at 10 a.m. to Resident 106, as prescribed by Resident 106's physician, since both medications were not available in the medication cart. LVN 11 stated that these mediations were not available in the Medication Room either and that LVN 11 did not have access to the Central Supply Room (a room that stores additional stock of house supply [not resident specific] medications) to check for availability. LVN 11 stated that usually a Central Supply Employee (CSE) would make rounds daily before the morning medication administration time to replenish medications, however LVN 11 had not seen that individual that morning (10/22/24.) LVN 11 stated that medications should be readily available to ensure timely administration at the scheduled times. LVN 11 stated it was important to receive these medications as ordered by the physician, and missing doses of these medications can harm Resident 106 by causing worsening uncomfortable gas and vitamin deficiency. During an interview on 10/22/24 at 10:20 a.m. with Registered Nurse (RN) 3, RN 3 that Central Supply Room had stock of medications, but licensed nursing staff did not have access to that room. During an observation and concurrent interview in Central Supply Room, on 10/22/24 at 10:30 a.m. with Central Supply Employee (CSE) 1, the room contained several Renal multivitamin medication bottles stored on the shelf and no bottles of simethicone were found. The CSE 1 stated that the Director of CS (DCS) was not currently in the facility and had gone to the off-site warehouse to bring simethicone since there were none available in the Medication Room and Central Supply Room. CSE 1 stated that only CSEs had access to the Central Supply Room and that licensed nurses were unable to access the room. During an interview on 10/22/24 at 10:42 a.m. with the Director of Nursing (DON,) the DON stated that licensed nurses were able to obtain medications from the Medication Room and did not have access to the medications stored in the Central Supply Room. The DON stated that licensed nurses needed to have access to medications throughout the facility and not rely on CSEs to ensure timely administration of medications to residents. The DON stated that medications should be administered within a 60-minute window from the time scheduled and that medications administered after that were considered late and a medication error. The DON stated that there should be no reason why licensed nurses should not have access to medications in the facility and no reason for them to wait for CSEs to grant access to the medications. The DON stated that as a result simethicone and renal multivitamin were not administered at the scheduled time at 9 a.m. on 10/22/24 to Resident 106. During an interview on 10/22/24 at 10:56 a.m., with the Director of Central Supply (DCS) and in the presence of DON, the DCS stated that simethicone was not available in the facility that day (10/22/24) and that DCS had gone to the off-site warehouse to obtain a supply. The DCS stated that licensed nurses did not have access to the Central Supply Room. The DCS stated that licensed nurses not having access to Central Supply Room and relying on CSEs daily rounds to replenish stock had caused the unavailability of mediations in the medication carts and late administration of simethicone and Renal multivitamin to Resident 106 that day (10/22/24.) The DCS stated that the current process was not efficient and not in the best interest of the residents in ensuring they receive medications at the scheduled times. The DON stated that the process was failing and there needed to be a change to always make medications more accessible to licensed nurses. During an interview on 10/22/24 at 12:35 p.m., with CSE 2, CSE 2 stated that licensed nurses did not have access to the Central Supply Room. CSE 2 stated that licensed nurses should have access to the room specially during an emergency where they can easily access the medications instead of waiting and relying on CSEs. During an interview on 10/22/24 at 12:56 p.m., with LVN 11 and CSE 2, LVN 11 and CSE 2 stated that licensed nurses needed to have access to medications from the Central Supply Room and that the current process of relying on CSE's to replenish the medications were causing delays in residents receiving medications on time. During an observation on 10/23/24 at 9:50 a.m., in Medication Cart 10, LVN 13 was observed administering vitamin C, multivitamin with minerals, Miralax (a medication used for constipation,) docusate (a medication used for constipation,) Keppra (a medication used for seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness,]) Eliquis (a medication used for thinning blood,) potassium chloride (a supplement used for low potassium levels) via G-tube followed by administering artificial tears in each eye to Resident 44, and was observed not administering labetalol to Resident 44 via G-tube. During an interview on 10/23/24 10:10 a.m., with LVN 13, LVN 13 stated that LVN 13 failed to prepare and administer labetalol 100 mg tablet during the morning medication administration at 9:50 a.m. to Resident 44, as prescribed by Resident 44's physician. LVN 13 acknowledged the physician's order specified to administer labetalol 100 mg at 9 a.m. and that LVN 13 overlooked and missed to administer the medication. LVN 13 stated, per facility policy, there was a 60-minute window for medication administration and that not administering within that window was considered a medication error. LVN 13 stated not administering the 9 a.m. dose of labetalol on 10/23/24 as ordered by the physician placed Resident 44 at the risk of having elevated high blood pressure potentially harming Resident 44 by causing a stroke resulting in hospitalization and/or death. LVN 13 stated that LVN 13 will immediately administer the labetalol to Resident 44. During an interview on 10/23/24 at 3:57 p.m. with the DON, the DON stated that residents should be administered as per physician orders at the scheduled times. Resident 44 was not administered labetalol 100 mg at 9:50 a.m. on 10/23/24 as LVN 13 overlooked to prepare and administer the medication, and Resident 106 was not administered simethicone 80 mg and renal multivitamin at 10 a.m. on 10/22/24 by LVN 11 due to the medications not being available in the medication cart and LVN 11 not having access to the Central Supply Room stock. The DON stated that these were considered medication error. The DON stated that simethicone was not available in the facility on 10/22/24. The DON stated Resident 44 was prescribed simethicone for abdominal distention and renal multivitamin for renal supplementation and Resident 106 was prescribed labetalol for hypertension. The DON stated missing the administrations of these medications can cause worsening abdominal distention, vitamin deficiency, elevated blood pressure and heart rate leading to potential heart attack and stroke. During a review of Resident 44's admission Record (a document containing demographic and diagnostic information,) [undated,] the admission Record indicated Resident 44 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including essential hypertension (high blood pressure that develops over time.) During a review of Resident 44's Physician Orders (a report listing the physician order for the resident), from 10/1/24 to 10/31/24, indicated Resident 44 was prescribed labetalol 100 mg tablet via G-tube every 12 hours for hypertension, starting 9/21/23. During a review of Resident 44's clinical record including physician orders, progress notes and nurses notes, the clinical record did not contain documentation that Resident 44 should not be administered labetalol on 10/23/24. During a review of Resident 44's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for October 2024, the MAR indicated Resident 44's labetalol 100 mg tablet was due twice a day at 9 a.m. and 9 p.m. The MAR indicated there was no documentation for the labetalol 100 mg administration on 10/23/24 for the 9 a.m. dose. During a review of Resident 106's admission Record, [undated,] the admission Record indicated Resident106 was originally admitted to the facility on [DATE] with diagnoses including end stage renal disease (irreversible kidney failure,) renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed,) constipation. During a review of Resident 106's Physician Orders, from 10/1/24 to 10/31/24, the Physician Orders indicated Resident 106 was prescribed: 1. simethicone 80 mg tablet via G-tube three times a day for abdominal distention (swelling,) starting 9/19/24, 2. Renal multivita.m.in one (1) tablet via G-tube daily for supplement, starting 9/19/24. During a review of Resident 106's clinical record including physician orders, progress notes and nurse's notes, the clinical record did not contain documentation that Resident 106 should not be administered the above medications on 10/22/24. During a review and concurrent interview with LVN 13 of Resident 106's MAR, for October 2024, the MAR indicated Resident 106's: 1. Simethicone 80 mg tablet via G-tube three (3) times a day, at 9 p.m., 1 p.m. and 5 p.m. 2. Renal multivitamin one (1) tablet via G-tube daily, at 9 a.m. The MAR indicated the 9 a.m. doses for simethicone 80 mg and renal multivitamin were circled with the initials of LVN 13. LVN 13 stated that a circle with LVN initials on the MAR indicated that the medication was not administered. During a review of the facility's policy and procedures (P&P), titled Medication Pass, last revised May 2023, the P&P indicated The purpose of this policy is to provide a guideline on how to properly complete a Medication Pass. Procedures 1. Follow the 10 Patient Rights of giving medications. 3. Check medications against the MAR to be correct. 5. Give medications as ordered. General Reminders 1. You have 1 hour before and 1 hour after the administered time to complete medication pass. During a review of the facility's P&P, titled Medication Pass Via Gtube/Jtube, last revised May 2020, the P&P indicated The purpose of this policy is to provide a guideline on how to pass medications through the Gastrostomy/Jejunostomy Tube. 7. Follow the 10 Patient Rights of giving medications. During a review of the facility's P&P, titled Medication Administration Techniques, last revised 10/25/23, the P&P indicated: Prior to passing meds 5. Start pass in a timely manner: time allotted for pass is two hours, one hour before to one hour after the scheduled administration time. 6. Observe 10 Medication Rights: 5. Right Time During the pass 3. Dispense/prepare medications as per M.D. (Medical Doctor/physician) orders. During a review of the facility's P&P, titled 10 Medication Rights, last revised July 2022, the P&P indicated The purpose of this policy is to provide current guidelines for Medication Patient Rights. 5. Right Time - Administering medications at a time that was intended by the prescriber. During a review of the facility's P&P, titled Medication Error Policy and Record Completion, last revised March 2024, the P&P indicated A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm or no harm while the medication is in control of the health care professional. Types of Medication Errors 4. Administration Error - Types of administration errors include: wrong patient, dose, time, medication route, rate, omission, and unauthorized dose given.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for one (1) out of five (5) sampled residents (Resident 81) investigated under unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: During a review of Resident 81's admission Record, the admission Record indicated the facility admitted the resident on 3/25/2023 and readmitted in the facility on 8/19/2024 with diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe] to facilitate breathing), and type diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 81's History and Physical (H&P) dated 4/22/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 81's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/29/2024, the MDS indicated Resident 81 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 81 was receiving insulin. During a review of Resident 81's Physician Orders, the Physician Orders indicated the following: - 8/19/2024: Fingerstick blood sugar check every six (6) with regular human insulin (a short acting insulin that starts to work within 30 minutes to 1 hour of injection) 100 units per milliliter (unit/ml - a unit of measurement) insulin per sliding scale coverage as: 70-140 = zero (0) unit (a unit of measurement); 141-180 = one (1) unit; 181- 200 = two (2) units; 201-250 = three (3); 251-300 = four (4) units; 301 - 350 = 6 units; 351 - 400 = eight (8) units; more than (>) 400 call physician. - 8/19/2024: Humulin N NPH (an intermediate-acting insulin that takes 4 hours to start working after injection) U-100 insulin 100 units/ml suspension inject seven (7) units SQ every 12 hours hold if blood sugar less than 100. During a concurrent interview and record review on 10/23/2024 at 3:30 p.m., reviewed Resident 81's Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident) from 8/2024, 9/2024, and 10/2024 with Registered Nurse 2 (RN 2), RN 2 verified the MAR indicated the Humulin N NPH and Regular insulin injection were administered as follows: Humulin N: - 8/20/2024 6:00 a.m. SQ left lower quadrant (LLQ) - 8/20/2024 6:00 p.m. SQ LLQ - 8/22/2024 6:00 a.m. SQ right lower quadrant (RLQ) - 8/22/2024 6:00 p.m. SQ RLQ - 8/23/2024 6:00 a.m. SQ left upper quadrant (LUQ) - 9/2/2024 6:00 p.m. SQ LLQ - 9/3/2024 6:00 a.m. SQ LLQ - 9/4/2024 6:00 a.m. SQ RLQ - 9/4/2024 6:00 p.m. SQ RLQ - 9/5/2024 6:00 a.m. SQ LUQ - 9/5/2024 6:00 p.m. SQ LUQ - 9/7/2024 6:00 a.m. SQ RLQ - 9/7/2024 6:00 p.m. SQ RLQ - 9/16/2024 6:00 a.m. SQ LLQ - 9/16/2024 6:00 p.m. SQ LLQ - 9/20/2024 6:00 a.m. SQ RLQ - 9/20/2024 6:00 p.m. SQ RLQ - 10/4/2024 6:00 a.m. SQ left arm (LA) - 10/4/2024 6:00 p.m. SQ left arm (LA) - 10/15/2024 6:00 a.m. SQ RLQ - 10/15/2024 6:00 p.m. SQ RLQ - 10/17/2024 6:00 a.m. SQ RLQ - 10/17/2024 6:00 p.m. SQ RLQ Regular insulin: - 9/2/2024 12:00 p.m. SQ RLQ - 9/2/2024 6:00 p.m. SQ RLQ - 9/3/2024 12:00 a.m. SQ LLQ - 9/3/2024 6:00 a.m. SQ LLQ - 9/3/2024 12:00 a.m. SQ RLQ - 9/3/2024 6:00 a.m. SQ RLQ - 9/11/2024 6:00 a.m. SQ RLQ - 9/11/2024 12:00 p.m. SQ RLQ - 9/14/2024 6:00 p.m. SQ LLQ - 9/15/2024 12:00 a.m. SQ LLQ - 9/15/2024 6:00 p.m. SQ RLQ - 9/16/2024 12:00 a.m. SQ RLQ - 9/19/2024 6:00 p.m. SQ RLQ - 9/20/2024 12:00 a.m. SQ RLQ - 9/21/2024 6:00 a.m. SQ RLQ - 9/21/2024 12:00 p.m. SQ RLQ - 9/21/2024 6:00 p.m. SQ RLQ - 9/22/2023 6:00 a.m. SQ LLQ - 9/22/2023 12:00 p.m. SQ LLQ - 9/27/2024 6:00 p.m. SQ LLQ - 9/28/2024 12:00 a.m. SQ LLQ - 10/8/2024 6:00 a.m. SQ right upper quadrant (RUQ) - 10/8/2024 12:00 p.m. SQ RUQ - 10/9/2024 6:00 a.m. SQ LLQ - 10/9/2024 12:00 p.m. SQ LLQ - 10/12/2024 12:00 p.m. SQ RLQ - 10/12/2024 6:00 p.m. SQ RLQ - 10/14/2024 12:00 p.m. SQ LLQ - 10/14/2024 6:00 p.m. SQ LLQ - 10/16/2024 12:00 p.m. SQ RLQ - 10/16/2024 6:00 p.m. SQ RLQ RN 2 stated insulin administration should be rotated per standards of practice. RN 2 stated Resident 81's MAR indicated the insulin administration sites were not rotated. RN 2 stated not rotating the injection sites placed the resident at risk for developing bruising, pain, and tenderness on the administration sites. RN 2 stated the skin underneath can develop lumps and affect the medication absorption. During a concurrent interview and record review on 10/25/2024 at 10:50 a.m. reviewed Residents 81's MAR from 8/2024, 9/2024, and 10/2024 with the Director of Nursing (DON). The DON stated the nurses should rotate the insulin administration sites as a standard of practice. The DON verified the insulin administrated were not rotated on multiple occasions. The DON verified the manufacturer's guideline for the use of Humulin N and Regular Insulin indicated to rotate the injection sites. The DON stated the nurses did not follow the manufacturer's guideline and the standards of practice. The DON stated the insulin administration sites should have been rotated as it can affect the absorption of insulin and can also cause skin lumps and bruising. The DON stated not rotating insulin administration site is considered a medication error according to the manufacturer's guideline and standards of practice. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed 1/18/2024, the P&P indicated to administer the insulin using proper subcutaneous technique. During a review of the facility provided manufacturer's guideline for Humulin R (insulin human), undated, the guideline indicated: - Change (rotate) the injection sites within the area chosen with each dose to reduce the risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. - Do not use the exact same spot for each injection. - Do not inject where the skin has pits, is thickened, or has lumps. - Do not inject where the skin is tender, bruised, scaly, or hard, or into scars or damaged skin. During a review of the facility provided manufacturer's guideline for Humulin N, undated, the guideline indicated: - Administer in the SQ tissue of the abdominal wall, thigh, upper arm, or buttocks. - To reduce the risk of lipodystrophy, rotate the injection site within the same region from one injection to the next. During a review of the facility's policy and procedure (P&P) titled, Medication Error Policy and Record Completion, last reviewed 1/18/2024, the P&P indicated a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm or no harm while the medication is in the control of the healthcare professional. The P&P indicated administration error is one of the types of medication error which include wrong patient, does, time, medication route, rate, omission, and unauthorized dose given.

Based on observation, interview, and record review the facility failed to 1. Store one (1) lorazepam (a medication used to treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) vial (form of medication that is used for injections) for Resident 7 in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of three (3) inspected medication refrigerators (Refrigerator 2) located in Nursing Station Subacute. 2. Remove and discard from use one (1) open and expired lorazepam vial for Resident 11, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of three (3) inspected medication refrigerators (Refrigerator 2) located in Nursing Station Subacute. 3. Store one (1) Epogen (brand name medication for epoetin alfa used to treat anemia [having low red blood cells) vial for Resident 92 in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of three (3) inspected medication refrigerators (Refrigerator 1) located in Nursing Station Subacute. These deficient practices increased the risk for Resident 7, 11 and 92 to receive medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization. Findings: During an observation, on 10/23/24 at 11 a.m., with the Director of Nursing (DON,) in Nursing Station Subacute, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One (1) opened vial of Epogen for Resident 92 was found stored in Refrigerator 1 in Nursing Station Subacute and not labeled with a date when use first began or when the vial would expire. According to manufacturer's product storage and labeling, Epogen multi-dose (containing more than one dose) vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and once opened to be discarded after 21 days. 2. One (1) open lorazepam multi-dose vial for Resident 7 was found stored in Refrigerator 2 in Nursing Station Subacute and without a label indicating when use began and an additional label indicating expires 28 days after opening and to discard. 3. One (1) open lorazepam multi-dose vial for Resident 11 was found stored in Refrigerator 2 in Nursing Station Subacute and labeled with a date indicating that use of the vial began on 8/24/24, and an additional label indicating expires 28 days after opening. During a concurrent interview with the DON, the DON stated the Epogen vial for Resident 92 was open and not labeled with a date indicating when use first began, the lorazepam vial for Resident 7 was open and not labeled with a date indicating when use first began, and the lorazepam vial for Resident 11 was open and labeled with a date indicating use of the vial began on 8/24/24. The DON stated multi-use vials were good for 28 days from when first opened and used, and without knowing when use first began the Epogen vial for Resident 92 and lorazepam vial for Resident 7 were considered expired and should not be used due to unknown expiration date. The DON stated the lorazepam vial for Resident 11 was expired. The DON stated expired Epogen and lorazepam vials have decreased medication potency (effectiveness) and when used in error could be ineffective by not treating or controlling Resident 92's anemia and Resident 7's and 11's seizures possibly leading to hospitalization. The DON stated all three (3) vials needed to be removed from Refrigerator 1 and 2 and disposed of to prevent accidental use for residents. The DON stated several LVN's failed to label with a date when use began and remove expired multi-dose vials from Refrigerator 1 and 2. During a review of the facility's Policy and Procedures (P&P,) titled Injectable Medications, dated October 2018, the P&P indicated: A. All injectable medications must be dated when first opened/punctured. If an injectable mediation is found open but not dated, the nurse should denote a date opened using the date it was dispensed by the pharmacy if still within appropriate shelf-life range. B. All other MDV will expire 28 days after opening per USP Guidelines unless otherwise specified. During a review of the facility's reference guide, titled Expiration Dates After Opening, dated October 2018, the guide indicated: Medications manufactured in multiple dose vials for injection not listed below or indicated on pharmacy label will follow the USP guideline of a 28-day expiration after opening. Procrit (brand name for epoetin alfa) MDVa - expiration 21 days refrigerated. a-be sure to document DATE WHEN OPENED on all vial for injection and all other multi-dose medications with a shortened shelf-life once seal is broke (such as a punctured vial) (month/day/year). During a review of the facility's P&P, titled Expired Medications, last revised on 6/7/20, the P&P indicated: Medications that are expired are given to DON for proper disposal. 4. Daily checks of the refrigerators in each unit are to be inspected for expired medications. Medications that are expired will be given to the DON for proper disposal. During a review of the facility's P&P, titled Storage of medications requiring refrigeration, last revised on 5/1/20, the P&P indicated: 3. Refrigerated medications will be audited for expiration, contamination, usability or recall by the primary care nurses and charge nurses on a daily basis.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. One cell phone was placed in the dry storage area next to boxes of nutritional supplements. 2. One dented can was placed in the non-dented can area in the dry storage area. 3. Two cans of sodas were found on the floor beneath the shelves in the dry storage area. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 20 of 111 residents who receive food from the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Supervisor (DS), on 10/22/2024, at 8:16 a.m., inside the kitchen's dry storage area, the DS confirmed a staff member's cell phone was placed next to boxes of nutritional supplements. The DS further stated personal belongings do not belong in food storage areas to prevent cross-contamination between personal belongings and food. During an interview with the Director of Nursing (DON), on 10/22/2024, at 4:45 p.m., the DON stated there should be a proper place to store personal belongings for the kitchen staff to prevent cross-contamination with the residents' food. During a review of the facility's policy and procedure (P&P) titled, Employee Personal Belongings, last reviewed 4/25/2022, the P&P indicated all working staff will store their personal belongings which include but not limited to handbags, back packs, cell phones, food etc. in a separate designated area. The P&P further indicated no personal belongings will be placed in food storage and preparation areas at any given time. 2. During a concurrent observation and interview with the DS, on 10/22/2024, at 8:16 a.m., inside the kitchen's dry storage area, the DS confirmed a can of mandarin oranges had a dent on its side and was placed in the canned goods area. The DS stated cans are checked for dents, openings, and breaks upon delivery and are separated for return, if observed. The DON further stated it is important to not serve food from dented cans or foods with damaged packaging due to the potential for cross-contamination. During an interview with the DON, on 10/22/2024, at 4:45 p.m., the DON stated dented cans should not be stored with the non-dented cans due to the potential for cross-contamination. During a review of the facility's P&P titled, Food Storage - Dented Cans, last reviewed 4/25/2022, the P&P indicated all dented cans and rusty cans are to be separated from remaining stock and placed in a specified area for return to vendor for refund. During a review of the facility's P&P titled, Food and Formula Storage - Dry, last reviewed 4/1/2022, the P&P indicated dented or damaged cans should be returned to the vendor for replacement or refund and the cans should be placed in an area of storage designated for damaged goods. 3. During a concurrent observation and interview with the DS, on 10/22/2024, at 8:16 a.m., inside the kitchen's dry storage area, the DS confirmed two cans of soda on the floor below the bottom of a shelf and stated no food items should be on the floor. The DS further stated if food items are found on the floor, there is a potential for cross-contamination. During an interview with the DON, on 10/22/2024, at 4:45 p.m., the DON stated food items should not be stored on the floor to prevent cross-contamination and prevent the spread of infection. During a review of the facility's P&P titled, Food and Formula Storage - Dry, last reviewed 4/1/2022, the P&P indicated food items shall be stored at least six inches above the floor on shelves or racks which facilitate cleaning. The P&P further indicated floors will be cleaned every shift and maintained free of food and debris and items found to be dropped on the floor will be discarded.

Based on observation, interview, and record review the facility failed to ensure safe and sanitary storage, handling, and consumption of foods for one of one sampled residents (Resident 53) investigated during review of kitchen facility task by failing to ensure food brought from home were labeled with resident's name, and the date and time the food was brought into the facility for resident's consumption. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 53, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever that can lead to other serious medical complications and hospitalization. Findings: During a review of Resident 53's admission Record (AR), the AR indicated the facility admitted the resident on 5/22/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), dependence on respirator (a mechanical device that helps a patient breathe by moving air into and out of their lungs), and hypoglycemia (low blood sugar level). During a review of Resident 53's History and Physical (H&P), dated 5/22/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 53's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/2/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was receiving a therapeutic diet. During an observation of resident refrigerator 1 and interview on 10/25/2024, at 10:20 a.m., with Registered Nurse 2 (RN 2) and Registered Nurse 5 (RN 5), in Station A, observed an open bottle of honey inside the refrigerator labeled with a resident's room number. RN 2 and RN 5 both stated the bottle of honey should have been dated when it was first opened. RN 2 stated the bottle of honey should be dated to ensure the food was not spoiled or expired. RN 5 stated not labeling the bottle of honey with the date it was first opened could lead to resident ingesting expired or spoiled food that can cause gastrointestinal (relating to or including both stomach and intestine) symptoms such as stomach ache, diarrhea, or vomiting. During an interview on 10/25/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated the staff should have placed the date, name of the patient and the time they opened the resident's food from home to ensure the food is not expired to prevent gastro intestinal problems brought about by ingestion of spoiled substances. During a review of the facility's recent policy and procedure (P&P) titled Food Brought in by Visitors, last reviewed on 1/18/2024, the P&P indicated the food will be appropriately labeled with date, time, and name of the resident. Food served within 72 hours will be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** f. During a concurrent observation and interview on [DATE], at 10:05 a.m., with Licensed Vocational Nurse 15 (LVN 15), in the facility hallway, Linen Cart A was covered with a permeable/loosely woven material to protect the clean linens for the residents to use. LVN 15 stated Linen Cart A cover does not protect the linen from splashes and minute viruses and bacteria due to the mesh/permeable material used. LVN 15 stated the permeable/loosely woven cover can let water splashes in, viruses and bacteria. During a concurrent observation and interview on [DATE], at 10:23 a.m., with Licensed Vocational Nurse 3 (LVN 3), in the facility hallway, Linen Cart B was covered with a permeable/loosely woven material to protect the clean linens for residents to use. LVN 3 stated the material they use to cover the linen carts can allow water and air inside that cannot prevent waters splashes and minute bacteria and viruses to get in. During a concurrent observation and interview on [DATE], at 10:40 a.m., with the Maintenance Supervisor (MS), near the pediatric unit, linen cart C was covered with a permeable/loosely woven material. The MS stated the material they are using to cover the clean linens have holes in them that can let water and air pass through that is prone to contamination (the process of making something dirty). During an interview on [DATE], at 1:55 p.m., with the Director of Nursing (DON), the DON stated the material that the facility is using is loosely woven and it allows air and water to pass through the cover. The DON stated the cover is not able to protect the clean linens from environmental contaminants such as minute bacteria and viruses. During a review of the facility's recent policy and procedure (P&P) titled Linen Cart, last reviewed on [DATE], the P&P indicated a dust cover is placed on each clean linen cart to prevent dust and contamination. g.I During a review of Resident 83's admission Record (AR), the AR indicated the facility admitted the resident on [DATE], with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 83's physician's order (PO), dated [DATE], the PO indicated an order to place resident on enhanced standard/barrier precautions for presence of indwelling devices (a medical device that remains inside the body for a period of time). g.II. During a review of Resident 76's admission Record (AR), the AR indicated the facility admitted the resident on [DATE], with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. During a review of Resident 76's physician's order (PO), dated [DATE], the PO indicated an order to place on enhanced standard/barrier precautions for presence of indwelling devices. g.III. During a review of Resident 22's admission Record (AR), the AR indicated the facility admitted the resident on [DATE], with diagnoses including tracheostomy and gastrostomy. During a review of Resident 22's physician's order (PO), dated [DATE], the PO indicated an order to place on enhanced standard/barrier precautions for presence of indwelling devices. During a concurrent observation and interview on [DATE], at 10:17 a.m., with the Director of Staff Development (DSD), near Room A , HK 1 was cleaning an enhanced barrier precaution room wearing an apron and their upper limbs were exposed and not covered by PPE. The DSD stated HK 1 should wear a gown to protect her upper limb from contamination that she could spread to other residents. During a concurrent observation and interview on [DATE], at 10:19 a.m., with the DSD, near Room B , HK 2 was cleaning an enhanced barrier precaution room wearing an apron and their upper limbs were exposed and not covered by PPE. The DSD stated HK 21 should wear a gown to protect her upper limb from contamination that she could spread to other residents. During an interview on [DATE], at 1:55 p.m., with the DON, the DON stated the housekeepers should have worn a gown instead of an apron while cleaning an enhanced barrier room to protect themselves and prevent the spread of infection to other residents. The DON stated the apron cannot protect the whole body of the housekeeper from having their body contaminated due to the apron not having the sleeves to protect the upper torso. During a review of the facility's recent policy and procedure (P&P) titled Personal Protective Equipment (Donning and Doffing), last reviewed on [DATE], the P&P indicated personal protective equipment will be worn during resident care, and when there is a potential for splash or spray, or the resident's equipment will come in contact. Procedure: Donning: 1. Sanitize hands 2. [NAME] gown 3. [NAME] mask (surgical or N-95) as needed 4. [NAME] goggles 5. [NAME] gloves During a review of the facility's recent policy and procedure (P&P) titled Enhanced Standard Precautions (ESP) 2024, last reviewed on [DATE], the P&P indicated to wear gowns, gloves, goggles, and mask while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of HCP hands, clothes, and the environment.: Any care activity involving contact with environmental surfaces likely contaminated by the resident, including cleaning and disinfection performed by environmental services (EVS) personnel. h. During a review of the facility provided Monthly Temperature Log from 7/2024 to [DATE], the water temperatures were recorded as follows: Date Location Temperature (degrees F) [DATE] Peds 1-2 107/112 [DATE] Peds 1-2 110/110 [DATE] Peds Sink 1-2 110/110 During an interview on [DATE], at 11:34 a.m., with the Administrator (ADM), The ADM stated they maintain the water temperature at the facility from 105-120 degrees F. The ADM stated they are following the Centers for Disease Control and Prevention (CDC, is a US federal agency that works to protect public health) guidelines on Controlling Legionella in the facility. During an interview on [DATE], at 1:30 p.m., with the Maintenance Supervisor (MS) and the ADM, the MS stated they only check the temperature of the water once a month. The MS stated they keep the temperature between 105-120 degrees F and doesn't know where they based the temperature from. The MS stated the ADM knows where they got the parameter. The ADM stated they mistaken the water temperature measurement with the regulation regarding water temperature comfortable for residents. The ADM stated he understood that with the CDC water management maintenance program they have to keep the temperature of the water in the facility from 114 degrees to 120 degrees F to prevent growth of legionella in the water system. During an interview on [DATE], at 2 p.m., with the IP, the IP stated the water should be between 114-120 degrees F to prevent growth of Legionella in their water system. During an interview on [DATE], at 1:55 p.m., with the DON, the DON stated the facility should make sure they comply with the CDC guidance on water management system to prevent Legionella in the facility by making sure the water on the resident's room and the facility is in between 114 to 120 degrees F to prevent the growth of Legionella in their water system. During a review of the facility's recent policy and procedure (P&P) titled Risk management plan for Legionella Control, last reviewed on [DATE], the P&P indicated on the Legionella Environmental Assessment Form Legionella generally grow well between 77 degrees F and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure the sterile water bag for the mechanical ventilation (a machine that does the work of breathing when a person is not able to) heater water chamber (a device that humidifies [adds moisture] the airway during mechanical ventilation) was replaced every three days per facility policy for one of four sampled residents (Resident 26) 2. Ensure the ventilator circuit tubing (tubing that connects the resident to the ventilator) was changed after being on the ground for one of four sampled residents (Resident 12). 3. Ensure a used inner cannula (removable hard plastic tube in the tracheostomy [opening surgically created through the front of the neck and into the windpipe]) was not left in the resident's bed for one of one sampled resident (Resident 95) 4. Ensure the Yankauer (a device used to suction fluids and debris from the airway) was not hanging from the left side of the resident's bed without a cover for one of one sampled resident (Resident 95) 5. Ensure Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) were implemented for one out of four sampled residents (Resident 87) investigated during a random observation when the X-ray Tech (a healthcare professional who performs medical examinations using X-rays [a test or way for physicians to get pictures of the inside of the body using radiation { energy that moves from one place to another in a form that can be described as waves or particles}] on patients to create images of specific parts of the body) did not wear a gown while obtaining X-rays of the resident. 6. Ensure Housekeeper 1 (HK1) and Housekeeper 2 (HK 2) wore a gown while cleaning an EBP room. 7. Ensure Licensed Vocational Nurse 10 (LVN 10) did not leave Medication Cart 4 inside a resident's room with an EBP sign on the door. 8. Ensure clean linens were protected from environmental contaminants a permeable (can be passed through, especially by liquids or gases)/loosely woven material to cover the linens. 9. Ensure the facility water system did not promote the growth of Legionella (a severe form of pneumonia caused by bacteria) when the facility water temperature was not kept between 114 to 120 degrees Fahrenheit (F, a scale for measuring temperature) in the facility. These deficient practices had the potential to spread infections and illnesses among residents and staff. Findings: a.During a review of Resident 26's admission Record , the admission Record indicated the facility admitted the resident on [DATE] and most recently readmitted the resident on [DATE] with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), dependence on a ventilator, and tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]). During a review of Resident 26's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required assistance with eating, personal hygiene, dressing, and toileting. During a review of Resident 26's physician orders, the orders indicated the following: -Send resident to the nearest emergency room via 911 for chest pain, dated [DATE]. -Re-admit resident from Hospital 1, status post pneumonia, dated [DATE]. -May use heated humidifier to prevent mucus (thick, slimy sticky fluid that lines and protects many parts of the body) plugs , dated [DATE]. During a concurrent observation and interview on [DATE] at 9:40 a.m., with Resident 26 in Resident 26's room, Resident 26 sat in bed connected to the ventilator with a humidifier and a bag of sterile water labeled with the date [DATE]. Resident 26 stated she recently returned from the hospital and had recovered from pneumonia. During a concurrent observation and interview on [DATE] at 10 a.m. with Respiratory Therapist 2 (RT 2) in Resident 26's room, RT 2 stated the bag of sterile water is used to provide moisture for the humidification of the resident's ventilator. RT 2 stated the sterile bags are changed every three days. RT 2 stated Resident 26's sterile water bag was dated [DATE] and should have been changed on [DATE] per the manufacture guidance, but it wasn't. RT 2 stated Resident 26 was hospitalized , and all the equipment should have been removed, including the sterile water bag. RT 2 stated she was not sure why a bag labeled [DATE] was in resident's room and connected to the humidifier. During an interview on [DATE] at 10:07 a.m., the Infection Preventionist (IP) stated the facility process is that when a resident is hospitalized and returns to the facility all the ventilator equipment should be changed. The IP stated Resident 26 returned from the hospital on [DATE] and it was possible the sterile water bag was mislabeled. The IP stated there was also a possibility the resident was reconnected to the ventilator system with a sterile water bag dated [DATE] when she returned from the hospital. The IP stated the importance of ensuring the sterile water bag is changed every three days is to prevent the growth of bacteria potentially resulting in infections and pneumonia in the resident. During an interview on [DATE] at 1:55 p.m. with the Director of Nursing (DON), the DON stated the sterile water bags used for the ventilator heat chambers are changed every three days and labeled with the date the bag is connected to the system. The DON stated a sterile water bag dated [DATE] is considered expired and should not be used. The DON stated everything expired should be discarded because it may potentially cause an infection in the resident if used past the expiration. The DON stated the facility policy was not followed when Resident 26 was connected to the ventilator with a sterile water bag labeled [DATE]. During a review of the facility policy and procedure titled, Heater and Heat and Moisture Exchange, last revised [DATE], it indicated the electric heater provides maximum humidification when the upper airway is bypassed during mechanical ventilation. Heater water chamber and sterile water must be attached to the device in order to provide moisture for humidification. A heat and moisture exchanger (HME) provides humidification when the upper airway is bypassed during mechanical ventilation. During a review of the facility policy and procedure titled, Equipment Changing - Shift Responsibilities, last revised [DATE], it indicated in order to adhere to the infection control guidelines, the Department of Respiratory Care will designate the following equipment changing responsibilities to the Respiratory Care Practitioners assigned to a particular shift and work area. An equipment change schedule has been established for the following items which are monitored by the Respiratory Care Director weekly/monthly: - Patients on continuous oxygen/aerosol systems, change when empty and as needed, not to exceed 72 hours. During a review of the facility policy and procedure titled, Infection Control Program, last reviewed 3/2024, it indicated the facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. b. During a review of Resident 12's admission Record , the admission Record indicated the facility admitted the resident on [DATE] and most recently readmitted the resident on [DATE] with diagnoses that included chronic respiratory failure, dependence on a ventilator, and tracheostomy. During a review of Resident 12's MDS dated [DATE], the MDS indicated the resident was in a persistent vegetative state (a chronic condition where a person appears to be awake but shows no awareness of their surroundings) / no discernible consciousness. The MDS further indicated the resident was dependent on staff for toileting, dressing, personal hygiene, bathing, oral hygiene, and mobility. During an observation on [DATE] at 11 a.m. in Resident 12's room, Resident 12 in bed connected to the ventilator circuit. The ventilator circuit tubing was resting on the floor. Certified Nursing Assistant (CNA) 1 sitting in a chair on the right side of Resident 12's bed. During a concurrent observation and interview on [DATE] at 11:05 a.m. with CNA 1 in Resident 12's room., CNA 1 stated she was caring for all the residents in the room. CNA 1 walked from the right side of the resident's bed to the left side and stated Resident 12's ventilator tubing was on the floor and of course it should not be there. CNA 1 picked up the resident's ventilator tubing and placed it on top of the stand with the ventilator equipment. CNA 1 returned to the chair and sat back down. During a concurrent observation and interview on [DATE] at 4:30 p.m. with Licensed Vocational Nurse 1 (LVN 1) in Resident 12's room., LVN 1 stated she was caring for Resident 12. LVN 1 assessed Resident 12's ventilator tubing and stated the tubing was dated [DATE] and had not been changed today. LVN 1 stated she was not told by CNA 1 that the tubing was on the floor. LVN 1 stated the CNA should have told her the tubing was on the floor because it should have been changed due to infection control issues. LVN 1 stated dirty tubing should not be placed on the vent stand because it may contaminate the equipment. LVN 1 stated something from the floor could get from the tubing or the contaminated ventilator stand to the resident's tracheostomy opening and cause an infection. During an interview on [DATE] at 10 a.m. with the IP, the IP stated circuit tubing should not be on the floor because bacteria from people's feet can get from the floor and eventually reach the resident. The IP stated the resident's tubing should have been changed immediately and not placed on the ventilator stand. The IP stated the tubing would cause cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) with the potential outcome of an infection in the resident. During a review of the facility policy and procedure titled, Equipment Changing - Shift Responsibilities, last revised [DATE], it indicated to adhere to the infection control guidelines, the Department of Respiratory Care will designate the following equipment changing responsibilities to the Respiratory Care Practitioners assigned to a particular shift and work area. An equipment change schedule has been established for the following items which are monitored by the Respiratory Care Director weekly/monthly: - For Ventilator Circuits and humidification systems; change the flex tubing every seven days and as needed. During a review of the facility policy and procedure titled, Infection Control Program, last reviewed 3/2024, indicated the facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. c.I. During a review of Resident 95's admission Record, the admission Record indicated the facility admitted the resident on [DATE] and most recently readmitted the resident on [DATE] with diagnoses that included chronic respiratory failure, dependence on a ventilator, tracheostomy, and sequelae of cerebral infarct (stroke, loss of blood flow to a part of the brain). During a review of Resident 95's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident required supervision with oral hygiene, required partial / moderate assistance with personal hygiene, required substantial / maximal assistance with mobility and dressing, and was dependent on staff for toileting. The MDS further indicated the resident required suctioning while a resident in the facility. During a review of Resident 95's physician orders, the orders indicated the following: -Ventilator dependent: change the inner cannula daily and as needed, dated [DATE]. -Suction tracheostomy secretions every two hours and as needed, dated [DATE]. During a review of Resident 95's Care Plan titled, Presence of Tracheostomy . ineffective airway clearance related to inability to expel excess secretions Potential for infection, initiated [DATE], indicated a goal that the resident would be always free from infections. During a concurrent observation and interview on [DATE] at 10:20 a.m. with Licensed Vocational Nurse 8 (LVN 8) in Resident 95's room, Resident 95 was lying in bed with multiple blankets at the foot of the resident's bed. Resident 95 stated she was cold. LVN 8 entered Resident 95's room and stated he would pull up the blankets. LVN 8 moved the blankets over Resident 95, and a slightly discolored inner cannula fell off the resident's left side of the bed onto the floor. LVN 8 pulled back the resident's covers and examined the tracheostomy area. LVN 8 then picked up the inner cannula off the floor and disposed of it. LVN 8 stated the resident's inner cannula must have gotten lost in the resident's bed when it was changed. LVN 8 stated the inner cannula was used and should not have been left in the resident's bed. During an interview on [DATE] at 10:30 a.m., with Respiratory Therapist 3 (RT 3), RT 3 stated Resident 95's inner cannula must have been changed and the old one should have been thrown away. RT 3 stated if a used cannula is left in the resident's bed it may cause the resident discomfort because it is made of hard plastic. RT 3 stated it is also a sanitary issue if the cannula is not disposed of and left in the bed. During an interview on [DATE] at 10 a.m. with the IP, the IP stated a used inner cannula should not be left in a resident's bed because it is an infection control issue. The IP stated a used inner cannula has secretions that may grow bacteria if not disposed of. The IP stated when tracheostomy care is provided there is a designated dirty area where the used supplies should be placed and then discarded. The IP stated when a used inner cannula is left in a resident's bed it may cause an infection in the resident and may also lead to the cannula causing a wound or a scratch on the resident's skin. During a review of the facility policy and procedure titled, Tracheostomy Care / Routine Daily Care / Inner Cannula Care, last reviewed [DATE], indicated tracheostomies will be kept clean and the airway clear of mucus. Tracheostomy care will be done daily and as needed. Equipment needed includes a plastic bag for waste. c.II. During an observation on [DATE] at 8 a.m. in Resident 95's room, Resident 95 laid in bed awake. A Yankauer was connected to tubing leading to a suction canister. The tubing of the Yankauer was secured to the left upper side bed rail with Velcro. The Yankauer hanging off the outside of the side bed rail and dangling towards the floor. During an interview on [DATE] at 8:05 a.m. with Licensed Vocational Nurse 9 (LVN 9), LVN 9 stated Resident 95 self-suctions with the Yankauer. LVN 9 stated when the Yankauer is not in use, it should be kept in a bag. LVN 9 stated there was probably a bag in the resident's bed. During a concurrent observation and interview on [DATE] at 8:15 a.m. with the IP in Resident 95's room, the IP stated the Yankauer was affixed to the bed by velcoVelcro and should not be hanging off the bed toward the floor. The IP stated the Yankauer should be kept in a bag when not in use. During a concurrent observation and interview on [DATE] at 8:20 a.m. with Certified Nursing Assistant 3 (CNA 3) and Resident 95 in Resident 95's room, CNA 3 looked in the linens on the bed where Resident 95 was laying, and stated there were no Yankauer bags in the resident's bed. Resident 95 stated she did not have a bag for the Yankauer. Resident 95 shook her head no when the Ssurveyor asked if the resident was told to keep the Yankauer in a bag. During an interview on [DATE] at 10 a.m. with the IP, the IP stated Yankauers are stored in a bag to keep microorganisms from contaminating the Yankauer and then being introduced into the mouth of a resident causing cross contamination. The IP stated cross contamination can lead to infection in residents. The IP stated the facility residents are very susceptible to infections due to their comorbidities and may become very sick from an infection that may ultimately lead to death. The IP stated the facility policy regarding suctioning was not followed because the policy indicates to keep the Yankauer in a bag. During a review of the facility policy and procedure titled, Suctioning - Oral, last reviewed [DATE], it indicated oral suctioning permits removal of secretions, maintains and clears the oral cavity when the resident is unable to expectorate. The Yankauer will be changed every Monday and Thursday by the night shift and as needed. The Yankauer sleeve will be labeled with the date. Replace Yankauer into designated sleeve and place in bag. During a review of the facility policy and procedure titled, Infection Control Program, last reviewed 3/2024, it indicated the facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. d. During a review of Resident 87's admission Record , the admission Record indicated the facility admitted the resident on [DATE] and readmitted in the facility on [DATE] with diagnoses including but not limited to chronic respiratory failure, tracheostomy, and gastrostomy tube (G-Tube - a tube inserted through the abdomen that delivers nutrition directly to the stomach). During a review of Resident 87's History and Physical (H&P) dated [DATE], the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 87's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 87's Physicians Orders, the physicians orders dated [DATE], it indicated to place Resident 87 on EBP for presence of an indwelling devices and a multidrug resistant organism (MDRO - bacteria that have become resistant to multiple antibiotics and are difficult to treat). During a review of Resident 87's care plan (CP) on alteration in health maintenance due to presence of MDRO and indwelling devices, on EBP initiated [DATE] last reviewed 9/2024, the CP indicated the following interventions but not limited to isolation precautions per facility protocol, and educate staff, family, visitors regarding type and isolation precaution protocols. During a concurrent observation and interview on [DATE] at 10:50 a.m. with Licensed Vocational Nurse 12 (LVN 12), outside Resident 87's room by the door LVN 12 verified Xray Tech repositioned Resident 87 to obtain x-ray and was not wearing a gown. LVN 12 stated Resident 87 was on EBP and the X-ray Tech should have been wearing a gown to prevent other residents from acquiring infection from not wearing a gown. LVN 12 then proceeded to instruct the X-ray Tech to put on a gown. During an interview on [DATE] at 10 a.m., the DON stated she was made aware the X-ray Tech was not wearing a gown while obtaining x-ray of the residents. The DON stated all healthcare personnel entering a resident room with an EBP sign should be wearing the personal protective equipment (PPE) prior to entering the room during high contact activities such as repositioning the resident to prevent spread of infection to vulnerable residents. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions 2024 last reviewed [DATE], the P&P indicated: -EBP will be used by clinical staff for specific high contact care activities to prevent transmission of colonized MDROs. -Wear gowns, gloves, goggles, and mask while performing the following high contact tasks associated with the greatest risk for MDRO contamination of healthcare personnel hands, clothes, and the environment but not limited to any care activity where close contact with the resident is expected to occur. During a review of the facility's P&P titled, Infection Control Program, last reviewed [DATE], the P&P indicated the facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. e. During a concurrent observation and interview on [DATE] at 11:35 a.m. with Licensed Vocational Nurse 11 (LVN 11) in Resident room [ROOM NUMBER] (Rm 9), Medication Cart 4 (Med Cart 4) was inside room [ROOM NUMBER] (Rm 9)LVN 11 verified the residents in RM [ROOM NUMBER] were on EBP as indicated on the EBP sign by the door and stated she placed Med Cart 4 inside RM [ROOM NUMBER] to minimize clutter along the hallway. LVN 11 stated she was told by another LVN that she can leave the medication cart inside the room. LVN 11 stated she should not have left Med Cart 4 inside RM [ROOM NUMBER] as it had the potential to contaminate the cart and contents on top including the pitcher of water, medication cups, and spoons and placed the residents at risk for being infected due to contaminated medical equipment. During an interview on [DATE] at 11:55 a.m., the Director of Nursing (DON) stated Med Cart 4 should not have been left inside RM [ROOM NUMBER] as the cart and contents of top can get contaminated and the residents can acquire infection due to contaminated medical equipment. The DON stated no medication cart should be left inside an EBP room. During a review of the facility's policy and procedure (P&P) titled, Infection Control Program, last reviewed [DATE], the P&P indicated the facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents[TRUNCATED]

Based on interview and record review, the facility failed to ensure an allegation of abuse including injuries of unknown source were reported immediately, but not later than 24 hours to the State Survey Agency (SSA), the Ombudsman Program (advocates for residents in nursing home) and law enforcement (police) in accordance with the facility's policy and procedure for one of three sampled residents (Resident 1). On 5/31/2024, Certified Nursing Assistant 1 (CNA 1) observed a fading greenish yellowish bruise (occurs when blood vessels break and leaked blood into the skins top layer) to Resident 1 ' s left jaw. This deficient practice resulted in no investigations conducted to rule out abuse and placed the residents at risk for further abuse. Findings: A review of Resident 1 ' s Record of admission indicated the facility admitted the resident on 3/5/2010, with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes your lungs into your blood), dependence on respirator (a machine that helps you breathe or breathes for you), unspecified (unconfirmed) cerebral palsy (group of conditions that affect movement and posture caused by damage that occurs to the developing brain) and essential hypertension (high blood pressure that is not due to another medical condition). A review of Resident 1 ' s Progress Note (History and Physical) dated 6/3/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/31/2024, indicated Resident 1 was dependent to staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions. A review of Resident 1 ' s Nursing Narrative Notes dated 6/2/2024 timed at 7:17 a.m., indicated, Resident 1 had a bruise on the left cheek and left side of the forehead endorsed by LVN 4 to RN 3. The Nursing Narrative Notes indicated RN 1 was notified. A review of Resident 1 ' s Physician Order dated 6/4/2024 indicated to monitor left lower jaw discoloration for significant changes. During an interview on 6/19/2024 at 9:49 a.m., Registered Nurse 1 (RN 1) stated she was the Charge Nurse on 6/4/2024 when Family Member 1 (FM 1) had a concern about Resident 1 ' s left jaw discoloration. RN 1 stated she did not see the discoloration, but she notified the physician. During an interview on 6/19/2024 at 10:25 a.m., the Director of Nursing (DON) stated they did not do an investigation because FM 1 did not notify them. During an interview on 6/19/2024 at 10:41 a.m., Certified Nursing Assistant 1 (CNA 1) stated on 5/31/2024 between 8 a.m., to 11 a.m., she gave a bed bath to Resident 1 and noticed a fading greenish yellowish bruise to Resident 1 ' s left jaw. CNA 1 stated she reported to LVN 2 and LVN 2 informed CNA 1 that it was already reported to RN 4. During an interview on 6/19/2024 at 11:15 a.m., the Director of Staff Development (DSD) stated if nurses notice any change in skin condition, they have to report it to the Charge Nurses, and the DON. During a concurrent interview and record review on 6/19/2024 at 11:57 a.m., with the DON, Resident 1 ' s Nurses Narrative Note dated 6/2/204 timed at 7:17 a.m., indicated, Resident 1 had a bruise on the left cheek and left side of the forehead. The DON stated nurses should report to the DON so they can assess the resident and investigate the injury. The DON stated an injury of unknown origin could have resulted from abuse. The DON stated it was not reported to the SSA, Ombudsman and the law enforcement agency. During a concurrent interview and record review on 6/19/2024 at 12:07 p.m., with the DON, facility ' s policy and procedure (PP) titled, Reporting of Alleged Abuse, neglect and Involuntary Seclusion dated 1/1/1999 and revised on 8/16/2022 was reviewed. The PP indicated, Injuries of unknown source: an injury should be classified as an injury of unknown source when both the following are met A. The source of injury was not observed by a person, or the source of the injury could not be explained by the resident. And the Injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. All licensed employees are considered Mandated Reporters . The investigation will be timely and will be given priority. Any authorities that need to be contacted example given, police Department, Ombudsman will be contacted within 24 hours, The Department of Health (SSA) will be contacted within two hours of the initial report. Types of Abuse that must be reported whether alleged or witnessed. 12. Injuries of unknown source. The DON stated it is their policy to report injury of unknown source to SSA, Ombudsman and Police Department. During an interview on 6/19/2024 at 12:09 p.m., the Administrator (ADM) stated he was not informed of the incident until today 6/19/2024.

Based on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) was wearing a protective gown while giving medications via gastrostomy tube (GT- a surgically placed device used to give direct access to the stomach for feeding, hydration or medicine) to Resident 1, who was placed on enhanced standard precaution (expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics]). This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminant from one surface to another) of infection among residents. Findings: A review of Resident 1 ' s Record of admission indicated the facility admitted the resident on 3/5/2010, with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes your lungs into your blood), dependence on respirator (a machine that helps you breathe or breathes for you), and essential hypertension (high blood pressure that is not due to another medical condition). A review of Resident 1 ' s Progress Note (History and Physical) dated 6/3/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/31/2024, indicated Resident 1 was dependent to staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions. A review of Resident 1 ' s Physician Orders dated 4/5/2024, indicated an order to place Resident 1 on enhanced standard precaution for presences of MDRO and indwelling devices. During an observation on 6/19/2024 at 8:38 a.m., inside Resident 1 ' s room. Observed Resident 1 ' s room with enhanced standard precaution signage posted by the door. Observed LVN 1 give medications through Resident 1 ' s GT without a protective gown. During an interview on 6/19/2024 at 9:19 a.m., the Infection preventionist (IP) stated he was informed by LVN 1 about the use of protective gown. The IP stated LVN 1 should wear a protective gown when giving medication thru the gt. During an interview on 6/19/2024 at 9:42 a.m., LVN 1 stated she forgot to wear the protective gown. LVN 1 stated she should have worn the gown to protect her from Resident 1 ' s secretions. During a concurrent interview and record review on 6/19/2024 at 10:33 a.m., with the IP, the facility ' s policy and procedure (PP) titled, Enhanced Standard Precaution dated 2024, was reviewed. The PnP indicated, The purpose for the use Enhanced Standard Precautions (ESP) of is to provide a guideline for the safe care of residents while preventing transmission of multi-drug resistant organisms (MDRO's). Enhanced Standard Precautions (ESP) will be used by clinical staff for specific high contact care activities to prevent transmission of colonized multi-drug resistant organisms (MDRO's). Wear gown, gloves, goggles, and mask while performing the following high contact associated with the greatest risk for MDRO contamination of healthcare partners hands, clothes, and the environment: A. Device care, for example, urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), feeding tube, tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), vascular catheter (flexible plastic tube that is inserted into a vein located either in the neck or in the groin). The IP stated the gown is to protect the nurses clothing from getting contaminated (infected by) with MDRO and to prevent transsmission to other residents. During an interview on 6/19/2024 at 11:57 a.m., the Director of Nursing (DON) stated nurses should wear a protective gown when giving medications through GT.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 109's admission Record indicated the facility admitted the resident on 9/11/2023 with diagnoses including spastic diplegic cerebral palsy (CP - a condition that is caused by abnormal brain development that affects a person's ability to control their muscles, mainly in the legs), epilepsy (brain disorder that causes recurring seizures), and neuromuscular dysfunction of the bladder (person lacks bladder control due to brain or nerve problems). A review of Resident 109's History and Physical, dated 9/14/2023, indicated the resident was non-verbal and had severe neurological impairment. A review of Resident 109's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff for dressing, feeding, personal hygiene, and all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 10/16/2023 at 10:08 a.m., Resident 109 was observed in bed with his urinary catheter drainage bag hanging on the right side of the bed without a privacy bag. During a concurrent observation and interview on 10/16/2023 at 10:08 a.m., Registered Nurse 7 (RN 7) stated Resident 109's urinary catheter drainage bag did not have a privacy bag. RN 7 stated that the urinary catheter drainage bag should be covered with a privacy bag to provide the resident privacy and dignity. During a concurrent interview and record review on 10/19/2023 at 10:13a.m., Resident 109's physician's order dated 9/19/2023 was reviewed with Registered Nurse 8 (RN 8). RN 8 stated the physician's order indicated monitoring must be done every shift to make sure the dignity bag for the suprapubic catheter was in place at all times. RN 8 stated it is important to cover the urinary bag with a dignity bag to provide the resident privacy. RN 8 stated that the missing dignity bag may negatively affect the resident's feelings. During an interview on 10/20/2023 at 9:09 a.m., the DSD stated that the missing dignity bag may potentially affect the dignity and privacy of Resident 109. During an interview on 10/5/2023 at 3:08 p.m., the DON stated Resident 109's urinary catheter drainage bag should have been covered with a privacy bag. The DON stated that all residents should be treated with respect and dignity to preserve their self-worth and self-esteem. A review of the facility's policy and procedure (P&P) titled, Privacy Cover for Urinary Drain Bags, reviewed 1/26/2023, indicated residents who have a urinary catheter with a drainage bag will use a Privacy Cover over the drainage bag to provide dignity and privacy. Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for two of 52 residents (Resident 80 and 109) by failing to ensure Resident 80 and Resident 109's urinary catheter bag (device used to collect urine drained from the bladder via a urinary catheter [a tube inserted into the bladder through the urethra (duct that lets urine leave the bladder and body) to allow urine to drain]) was covered with a privacy bag (also known as a dignity bag - device used to cover the contents or a urinary catheter bag). This deficient practice had the potential to affect the residents' self-worth and self-esteem. Findings: a. A review of Resident 80's Record of admission indicated Resident 80 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of Resident 80's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/26/2023, indicated Resident 80 was rarely or never understood and had an indwelling catheter (also known as a urinary catheter). A review of Resident 80's Physician Orders, dated 9/13/2023, indicated Resident 80 had an order for a dignity bag for their urinary catheter in place at all times. During an observation, on 10/16/2023, at 8:19 a.m., inside Resident 80's room, Resident 80's urinary catheter was hanging on the side of her bed without a privacy bag. During an interview with Treatment Nurse (TN) 1, on 10/19/2023, at 12:51 p.m., TN 1 stated Resident 80 has a urinary catheter and all residents with urinary catheters should have a dignity bag to respect a resident's privacy. TN 1 stated a dignity bag helps residents from being embarrassed and without a dignity bag, residents could feel uncomfortable from having their urinary catheters exposed. During an interview with the Director of Staff Development (DSD), on 10/20/2023, at 8:57 a.m., the DSD stated residents with urinary catheters should have a privacy cover for their urinary catheter bags to protect the privacy and dignity of the resident. The DSD further stated when urinary catheter bags are visible, it has the potential for residents to feel embarrassed from exposure. During an interview with the Director of Nursing (DON), on 10/20/2023, at 12:05 p.m., the DON stated a dignity cover should be applied to a resident's urinary catheter bag to protect their privacy. The DON stated the potential outcome of leaving a urinary catheter bag visible is that the residents can feel embarrassed from exposure of their urinary catheter.

Based on observation, interview, and record review, the facility failed to properly treat a resident's contractures (muscles or tendons that have remained too tight for too long, thus becoming shorter) by not applying bilateral hand splints and right knee splint as ordered by the physician for one of two sampled residents (Resident 22) investigated under the position, mobility care area. This deficient practice had the potential to result in the decline of the resident's mobility and range of motion (the extent or limit to which part of the body can be moved around a joint or a fixed point) and worsening of the resident's contractures. Findings: A review of Resident 22's Record of admission indicated the facility admitted the resident on 11/6/2008 and readmitted the resident on 5/23/2014, with diagnoses including convulsion (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review if Resident 22's History and Physical dated 5/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/29/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 22's Physician Orders indicated the following orders: 1. Apply bilateral hand splints daily by Restorative Nursing Assistant (RNA) dated 1/18/2018. 2. RNA daily right knee splint four to six hours as tolerated with skin checks dated 2/3/2023. A review of Resident 22's care plan indicated the following: 1. Potential for limitations and or decline in the range of motion (ROM) in some or all extremities updated on 5/15/2023 and last reviewed on 8/2023, indicated to apply splints properly when ordered. 2. Limitations in the functional ROM on the right knee, bilateral wrists and fingers updated on 5/2023 and last reviewed on 8/2023 indicated the following: a. Passive ROM to all extremities daily by RNA. b. Apply right knee splint. c. Bilateral hand splints. During an observation on 10/16/2023 at 10:40 a.m., observed Resident 22 without splints. The splints were observed inside the resident's closet. During a concurrent observation and interview on 10/16/2023 at 11:11 a.m., Restorative Nursing Assistant 1 (RNA 1) stated Resident 22 did not have the bilateral hand splints and right knee splint on, and the splints were stored inside the resident's closet. RNA 1 stated she applied the splints between 9 am and 10 am and she was not sure who removed the splints. RNA 1 stated the certified nursing assistants (CNAs) should have notified her that the splints were removed during ADL care so she could reapply the splints. RNA 1 stated the splints should have been reapplied because it is ordered by the physician and the resident is at risk for worsening of contractures. During an interview on 10/16/2023 at 11:30 a.m., Licensed Vocational Nurse 7 (LVN 7) stated that she did not observe Resident 22 with the bilateral hand splints and right knee splints on. LVN 7 stated the splints should have been reapplied after providing ADL care as it placed Resident 22 at risk for worsening of contractures if not applied as ordered by the physician. During an interview on 10/16/2023 at 1:56 p.m., Certified Nursing Assistant 1 (CNA 1) stated that she removed Resident 22's splints during ADL care. CNA 1 stated that she forgot to notify RNA 1 that she removed the splints. CNA 1 stated she should have notified RNA 1 to reapply Resident 22's splints to prevent worsening of contractures. During an interview on 10/18/2023 at 11:00 a.m., the Director of Staff Development (DSD) stated the CNAs were supposed to communicate with the RNAs every time they remove any residents' splints so the RNA's can reapply the splints. The DSD stated Resident 22's bilateral hand splints and right knee splint should have been reapplied as ordered by the physician as it placed the resident at risk for worsening of contractures. A review of the facility's policy and procedure titled, Hand Splints and Rolls, last reviewed on 1/26/2023, indicated hand splints and rolls are used positioning and prevention of contractures and will be applied and removed according to the physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 91's admission Record indicated the facility admitted Resident 91 on 10/5/2022, with diagnoses including persistent vegetative state (when a person is awake but is showing no signs of awareness), dysphagia (difficulty swallowing), and restlessness and agitation. A review of Resident 91's History and Physical (H&P), dated 10/6/2022, indicated Resident 91 was unresponsive, on decerebrate positioning (an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward). The MDS indicated Resident 91 was on dehydration/ fluid maintenance on the Care Area Assessment Summary 9used to evaluate resident improvement or decline in long term care facilities). A review of Resident 91's Physician Orders, dated 3/6/2023, indicated an order for: - May insert peripheral intravenous (IV, within a vein): Flushing and care by RN on duty. A review of Resident 91's care plan, last reviewed on 10/18/2023, indicated the resident was at risk for infection and or infiltration (the accidental leakage of the intravenous (IV) solution into the surrounding tissue instead of flowing into the vein) related to presence of saline lock. The care plan indicated interventions including assess IV site every (q) shift for signs and symptoms (s/s) of infection/infiltration/ thrombus (a blood clot that forms inside one of the veins or arteries) and report to MD and follow facility's protocol for IV site maintenance. During a concurrent observation and interview on 10/16/2023, at 9:46 a.m., with Licensed Vocational Nurse 8 (LVN 8), observed Resident 91's saline lock not dated and initialed by the licensed nurse who started the line. LVN 8 stated the IV site should be labeled for infection control. During an interview on 10/20/2023, at 8:40 a.m., the Director of Staff Development (DSD) stated it was important to label the IV site with the initial of the nurse who started the line and the date it was placed for infection control purposes. The DSD stated their policy indicated that the licensed nurse should initial and date the saline lock and indicate its expiration date. During an interview on 10/20/2023, at 9:36 a.m., with the Director of Nursing (DON), the DON stated the licensed nurses should label the saline lock with the date and initial of the nurse that started the saline lock for infection control. A review of the facility's recent policy and procedure titled, Intravenous Therapy, last reviewed on 1/26/2023, indicated assess the site of the current IV and patency of the line by inspecting for swelling, redness, or tenderness. Observe the site every shift and prn. A review of the facility's recent policy and procedure titled, IV Therapy Dressing and Tubing Care, last reviewed on 1/26/2023, indicated the purpose of this policy is to provide us with a guideline on the maintenance of an IV dressing and tubing. The dressing changes should be done every seven days and prn. a. Dressing should be dated, timed, and be initialed when complete. b. Dressing changed should be documented. Based on observation, interview, and record review the facility failed to ensure that each resident receives care and services for the provision of parenteral fluids (formulated liquids that are injected into a vein to prevent or treat dehydration [a condition caused by the loss of too much fluid from the body]) consistent with professional standards of practice for two out of two sampled residents (Residents 27 and 91) by failing to label the saline lock (a thin, flexible tube placed in a vein in the hand or arm) with the date and initials of the staff who started the saline lock. The deficient practice had a potential to cause infection such as phlebitis (inflammation of a vein). Findings: a. A review of Resident 27's Record of admission indicated the facility admitted the resident on 8/11/2023 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 27's History and Physical dated 8/22/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 27's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/2/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 27's IV Therapy Record - Peripheral Line, indicated there was no documented evidence when the peripheral line was started and when the site needs to be changed. During an observation on 10/16/2023 at 2:20 p.m., observed Resident 27 with IV catheter on the right hand with no date indicated on the dressing or tape. During a concurrent observation and interview on 10/16/2023 at 2:32 p.m., with Registered Nurse 1 (RN 1), RN 1 verified Resident 27's peripheral IV line did not indicate a date on the dressing or tape. RN 1 stated peripheral IV line sites are changed every seven (7) days. RN 1 stated Resident 27' s peripheral line should have indicated the date when it was last changed so the RNs would know when to change the site. RN 1 stated peripheral IV line sites need to be changed timely to prevent complications such as infection and swelling of the site. During a concurrent interview and record review on 10/20/2023 at 3:40 p.m., with Registered Nurse 3 (RN 3), Resident 27's IV Therapy Record was reviewed. RN 3 stated the peripheral line site did not indicate the date it was inserted and the next date the site will be changed. RN 3 stated the insertion should have been documented in the IV Therapy Record per facility policy so the nurses would know when to change the IV line site and for infection control. A review of the facility's policy and procedure titled, IV Therapy Dressing and Tubing Care, last reviewed on 1/26/2023, indicated dressing changes should be done every 7 days and as needed. The policy indicated the dressing should be dated, timed, and be initialed when complete. The policy indicated the dressing change should be documented.

Based on interviews and record reviews, the facility failed to act upon on the Pharmacist Consultant's monthly medication regimen review recommendations in a timely manner for one out of five sampled residents (Resident 103) investigated under the Unnecessary Medications, Psychotropic Medications (used to stabilize or improve mood, mental status, or behavior), and Medication Regimen Review care area, by failing to address the recommendation to change the administration time for Resident 103's sucralfate (antacid, used to treat and prevent ulcers/sores in the intestines) medication. This deficient practice had the potential to result in reduced effectiveness of the medication designed to form a protective barrier over the ulcer or damaged area in the gastrointestinal tract. Findings: A review of Resident 103's Record of admission indicated the facility readmitted the resident on 5/30/2023 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and encounter for attention to gastrostomy (a surgical procedure used to insert a tube, often referred to as a g-tube/GT, through the abdomen and into the stomach). A review of Resident 103's History and Physical, dated 6/2/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 103's Physician Orders, dated 5/30/2023, indicated sucralfate 1 gram (g, a unit of measure)/10 milliliters (ml, a unit of measure) oral suspension give 10 ml via GT every six hours, gastro-esophageal reflux disease (GERD, a condition in which the stomach contents leak backward from the stomach into the esophagus). A review of the Consultant Pharmacist's Medication Regimen Review, dated 7/9/2023, 8/5/2023, and 9/11/2023, indicated the recommendation for Resident 103: - Carafate (sucralfate) works by binding to the stomach wall, therefore it must be administered at least ½ hour before meals to have any effect. Please change the administration to 30 minutes before meals (AC) and at bedtime (HS?) from the current every six hours. During a concurrent interview and record review of Resident 103's Physician Orders with Registered Nurse 2 (RN 2), on 10/20/2023 at 10:52 a.m., RN 2 stated the current order for sucralfate was dated 5/30/2023. RN 2 stated there were no new orders placed for Resident 103. RN 2 stated the pharmacist consultant's recommendation should have been followed through as soon as possible. RN 2 stated she gave the pharmacist consultant recommendation letter to Resident 103's physician but was not on file. RN 2 stated if the letter was not on Resident 103's file, then it was not done. RN 2 stated she will follow-up with Resident 103's physician. During an interview on 10/20/2023 at 4:02 p.m., the Director of Nursing (DON) stated the RNs were responsible for following through with the pharmacist's recommendation. The DON stated RN 2 works on the medication regimen review. The DON stated the purpose of following through the pharmacy recommendation is to notify the resident's physician if they agree or not agree. The DON stated if the physician agrees to the recommendation, then a new order will be placed. A review of the facility's policy and procedure (P&P) titled, Medication Regimen Review, last reviewed and approved on 1/26/2023, indicated the regimen review will consist of the Pharmacy consultant doing the regimen review of medications monthly and make recommendations as needed. The P&P indicated the Physician will evaluate all medications upon their visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. On [DATE] at 1:12 p.m., during an observation of Medication Cart #9 in the presence of LVN 20, observed Betamet Dipro (medication used to treat eczema [a condition that causes your skin to become dry, itchy, and bumpy]) for Resident 109 with beyond-use date (expiration date) of [DATE]. During concurrent observation and interview, with Licensed Vocational Nurse 20 (LVN 20), on [DATE] at 1:12 p.m., LVN 20 stated the expired medication (Betamet Dipro) should be discarded as storing this medication has the potential to result in medication error. During an interview on [DATE] at 14:24p.m., the Pediatric Unit Manager ([NAME]) stated that all medications were brought from home on admission by Resident 109's mother, who insisted that they be kept with Resident 109. The [NAME] stated that for all medication brought from home, the nurses should obtain a physician's order and that expired medication should be discarded. During an interview on [DATE] at 14:24 p.m, the Director of Staff Development (DSD) stated that home medications were not supposed to be stored in the Medication Cart and that and physician's order need to be obtained before a resident uses a medication from home. The DSD stated that this practice creates the potential for medication error. During an interview on [DATE] at 14:24 p.m, the Director of Nursing (DON) stated that home medication has to be returned to the family and that keeping a resident's home medication in the facility medication cart can lead to mistakes. A review of the facility's policy and procedures for Supplements and medication from home, reviewed [DATE], indicated: Charge nurse will obtain a physician's order for all supplements or medications brought from home. Based on observation, interview, and record review, the facility: 1. Failed to ensure the potassium chloride (KCL - a medicine used to prevent or treat low potassium [a mineral the body needs for proper functioning of the heart, muscles, kidneys, nerves, and digestive system] levels in the body) oral solution label matched the dosage the physician's order and Medication Administration Record (MAR) for one of five residents (Resident 22) observed during the Medication Administration task. This deficient practice placed Resident 22 at risk for receiving the wrong dosage of the medication which may lead to muscle weakness, chest palpitation (a skipped, extra, or irregular heartbeat), and arrhythmia (irregular heartbeat). 2. Failed to obtain an order to change the Colace (a medicine that makes used to make bowel movements softer and easier to pass) softgel (a pliable soft gelatin capsule containing a liquid medication) to liquid form for Resident 22. This deficient practice placed Resident 22 at risk for not receiving the full amount of the medication which may lead to gastrointestinal distress (a group of disorders associated with constipation, bloating, reflux, nausea, vomiting, diarrhea, stomach pain, and cramping). 3. Facility failed to obtain a physician's order for Resident 109's medication from home and failed to discard the expired medication of the resident. This deficient practice creates the potential for administration of expired medication and potential for medication error. Cross reference to F658 Findings: a. A review of Resident 22's Record of admission indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses including convulsion (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (G-tube - a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review if Resident 22's History and Physical dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and screening tool) dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 22's Physician Orders indicated the following orders: 1. KCL 20 milliequivalent (mEq - a unit of measurement) 15 milliliters (ml - a unit of measurement) via G-tube, dilute with 200 ml water daily for supplement with an order date of [DATE]. 2. Colace 250 milligrams (mg - a unit of measurement) via G-tube every 12 hours, hold for diarrhea for bowel management with an order date of [DATE]. A review of Resident 22's Medication Administration Record (MAR) indicated the following: 1. KCL 20 mEq (15 ml) via G-tube dilute with 200 ml water daily for supplement. 2. Colace 250 mg via G-tube every 12 hours hold for diarrhea for bowel management. During a medication administration observation on [DATE] at 8:11 a.m., Licensed Vocational Nurse 1 (LVN 1) pulled out the bottle of KCL oral solution labeled with Resident 22's name from the medication cart and stated the MAR indicated to administer KCL 20 mEq. Observed label in the medication bottle indicated KCL 40 MEQ (30 ml) via G-tube daily dilute with 200 ml water with fill date of [DATE]. During a concurrent observation, interview, and record review on [DATE] at 8:11 a.m., reviewed the MAR and KCL bottle label with LVN 1. LVN 1 stated the medication bottle label indicated KCL 40 mEq (30 ml) via G-tube daily dilute with 200 ml water with fill date of [DATE]. LVN 1 stated the MAR indicated KCL 20 mEq (15 ml) via G-tube dilute with 200 ml water daily for supplement. LVN 1 stated if the label was different from the MAR, she will notify the charge nurse and check the physician's order. During a concurrent observation, interview, and record review on [DATE] at 8:42 a.m., reviewed the MAR and the medication label for KCL with Registered Nurse 5 (RN 5). RN 5 stated if the label was different from the MAR, she will check the physician's order and attach a Directions changed refer to chart sticker. RN 5 verified there was no sticker on the medication bottle. LVN 1 and RN 5 stated it was important that the medication label matched the physician's order and the MAR to ensure Resident 22 received the proper dosage of the medication. During an interview on [DATE] at 8:00 a.m., the Director of Nursing (DON) stated the medication label for the KCL should match the MAR and the physician's order unless there was a change of direction. The DON stated that if there was a change of direction, there should be a sticker attached on the medication bottle to refer to the chart and check the physician's order. The DON stated not attaching a direction changed sticker on the medication bottle placed Resident 22 at risk for receiving the wrong dosage which may lead to serious adverse side effects. A review of the facility's policy and procedure titled, Medication Labeling, last reviewed on [DATE], indicated the following: 1. Prescription medication will have the following information on the label: a. Name, strength, and quantity of drug b. Dose c. Expiration date If an order is changed on a prescription medication, a Directions changed refer to chart sticker will be placed on medication. b. During a Medication Administration task observation on [DATE] at 8:40 a.m., LVN 1 dispensed Colace 250 mg softgel from a medication bottle into a medicine cup and set it aside. LVN 1 stated the bottle of Colace was a house supply with an open date of [DATE] and expiration date of 6/2024. LVN 1 stated she will place the Colace softgel in hot water to melt the medication. During a concurrent observation, interview, and record review on [DATE] at 8:45 a.m., reviewed the MAR and the medication bottle with RN 5). RN 5 verified the bottle of Colace indicated softgel and the medications inside the bottle were softgels. RN 5 verified the MAR did not indicate the type or form of medication to be administered. RN 5 stated the physician needed to be notified to obtain an order to specify the Colace as liquid form. RN 5 stated if the softgel was placed in hot water, it had the potential to lose the medication potency or efficacy. During an interview on [DATE] at 8:00 a.m., the Director of Nursing (DON) stated the physician should be notified to obtain an order to change the Colace softgel to liquid form for appropriateness during medication administration via G-tube. The DON stated that placing the softgel in hot water was not acceptable as the medication can lose its potency or efficacy. A review of the facility's policy and procedure titled, Medication Labeling, last reviewed on [DATE], indicated the following: 2. Prescription medication will have the following information on the label: d. Name, strength, and quantity of drug e. Dose f. Expiration date If an order is changed on a prescription medication, a Directions changed refer to chart sticker will be placed on medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its antibiotic stewardship program for one of 52 sampled residents (Resident 23) by: 1. Failing to monitor and document Resident 23's erythromycin (a medication used as an antibiotic [medication used to treat bacterial infections] and gut motility [the process of moving food, liquids, and waste through the gut] stimulator) use in the facility's Resident Antibiotic Log for August, September, and October 2023. 2. Failing to indicate a duration in the physician's order for the use of erythromycin. These deficient practices placed Resident 23 at risk for adverse events, including the development of anti-biotic resistant organisms, from unnecessary or inappropriate antibiotic use. Findings: A review of Resident 23's Record of admission indicated Resident 23 was originally admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and dysphagia (difficulty or discomfort in swallowing). A review of Resident 23's Minimum Data Set (MDS - an assessment and care screening tool), dated 10/4/2023, indicated the resident was comatose (persistent vegetative state/no discernible consciousness), always incontinent (having no or insufficient voluntary control over urination or defecation) of bowel and bladder, and received nutrition via a feeding tube. A review of Resident 23's History and Physical, dated 12/7/2022, indicated the resident did not have the capacity to understand or make decisions. A review of Resident 23's Physician's Order, dated 11/23/2022, indicated an order for erythromycin 120 milligrams (mg - a unit of measure) via gastrostomy tube (GT - tube inserted into the stomach used to provide nutrition, hydration, and/or medication) every six hours for gastrointestinal (GI - relating to the stomach and intestines) motility. The Physician's Order did not indicate a duration for the use of erythromycin. A review of Resident 23's Resident Care Plan, dated 12/22/2022, indicated concerns and problems that included at risk for adverse effects due to long term use of antibiotic medications, including erythromycin 120 mg every six hours for GI motility. The care plan further indicated an approach plan to assess the resident for any signs and symptoms of infection, assess for signs and symptoms of adverse reactions and report to the physician. A review of the facility's Resident Antibiotic Log for Adults, dated between 8/2023 to 10/2023, indicated Resident 23's order for erythromycin 120 mg every six hours for GI motility was not documented in the log. During a concurrent interview and record review with the Infection Preventionist Assistant (IPA), on 10/20/2023, at 3:00 p.m., the facility's Resident Antibiotic Log for Adults, dated between 8/2023 to 10/2023, was reviewed. The IPA confirmed Resident 23's order for erythromycin 120 mg every six hours for GI motility was not documented in the log. The IPA further stated it is important to monitor Resident 23's order in the log because erythromycin is an antibiotic, and the resident is on continuous use. During a concurrent interview and record review with the Director of Nursing (DON), on 10/20/2023, at 3:36 p.m., Resident 23's Physician's Orders, dated 11/23/2022 and the facility's Resident Antibiotic Log for Adults, dated between 8/2023 to 10/2023, were reviewed. The DON stated Resident 23's order for erythromycin 120 mg every six hours for GI motility was not documented in the log and the order did not indicate a duration of use for the medication. The DON stated the physician's order should have included a duration because erythromycin is an antibiotic. The DON stated it is important to monitor the use of the medication for effectiveness, and to see if the medication is still needed or not. The DON stated if the medication is not being monitored, the resident may encounter some side effects from the long-term use of antibiotics. A review of the facility's policy and procedure (P&P) titled, Core Elements of Antibiotic Stewardship for [Facility], reviewed 1/26/2023, indicated the major objectives of antimicrobial (agent that destroys, or prevents the growth of microorganisms, such as antibiotics) stewardship are to optimize clinical outcomes for residents while minimizing toxicity (accumulation of too much prescription drugs in the bloodstream leading to negative effects) and other adverse events associated with antimicrobial use. The P&P indicated the Infection Preventionist (IP) will monitor the use of antibiotics for residents, gather data, follow laboratory results, and ensure that the appropriate antibiotic is used. The P&P further indicated the IP will complete antibiotic stewardship monitoring and enforcement. A review of the facility's P&P titled, Antibiotic Therapy, reviewed 1/26/2023, indicated the physician's order must include the following: a. The name of the antibiotic b. The dose of the antibiotic c. Frequency of the antibiotic d. Duration of the antibiotic e. And the reason for the antibiotic A review of the facility's P&P titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, reviewed 3/2023, indicated all resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form and the information gathered will include: a. Resident name b. Room number c. Name of antibiotic d. Start date of antibiotic e. Stop date f. Labs performed. A review of the facility's P&P titled, Orders for Antibiotics, reviewed 3/2023, indicated if an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name b. Dose c. Frequency of administration d. Duration of treatment (1) Start and stop date, or (2) Number of days of therapy e. Route of administration and f. Indications for use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' call lights are within reach for three (Resident 16, 22, and 51) of 52 sampled residents (Resident 16, 22, and 51). This deficient practice had the potential to result in a delay in or lack of necessary care and services that can negatively affect the resident's comfort and well-being. Findings: a. A review of Resident 16's admission Record indicated the facility admitted Resident 16 on 5/10/2019, with diagnoses including disorder of psychological development (impairments in a child's physical, cognitive, language, or behavioral development), intracranial injury (brain swelling inside the confined area of the skull because of the injury), and legal blindness. A review of Resident 16's History and Physical (H&P), dated 5/6/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/27/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS also indicated Resident 16 was severely visually impaired. A review of Resident 16's Care Plan, last evaluated on 8/2023, indicated Resident 16 had potential for falls and injury with an intervention to place call light within reach. During a concurrent observation and interview on 10/16/2023, at 9:58 a.m., with Licensed Vocational Nurse 5 (LVN 5), observed Resident 16's call light hanging on the left side of the bed in close proximity to the floor. LVN 5 stated the call light should be within the resident's reach so the resident can call for help if needed. During an interview on 10/20/2023, at 8:40 a.m., the Director of Staff Development (DSD) stated the staff should have kept the resident's call light within reach. The DSD stated not placing the call light within reach had the potential for the resident not being able to ask for help. During an interview on 10/20/2023, at 9:36 a.m., the Director of Nursing (DON) stated staff should keep the call light within the resident's reach so the resident can call staff for assistance. The DON stated not having the call light within reach had the potential for the resident's needs not being met and placed the resident at risk for falls. b. A review of Resident 22's Record of admission indicated the facility admitted the resident on 11/6/2008 and readmitted the resident on 5/23/2014 with diagnoses including convulsion (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement, chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review if Resident 22's History and Physical dated 5/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 22's care plan on potential for falls and injury related to convulsion, cerebral palsy (a group of conditions that affect movement and posture caused by brain damage), and muscle spasm updated on 5/15/2023 and last reviewed on 8/2023, indicated an intervention to place call light within reach. During a concurrent observation and interview on 10/16/2023 at 10:50 a.m., with LVN 7 in Resident 22's room, observed Resident 22's call light hanging on the pole next to the resident's bed. LVN 7 stated the call light should always be placed within the resident's reach. During an interview on 10/16/2023 at 1:40 p.m., Certified Nursing Assistant 1 (CNA 1) stated she forgot to place Resident 22's call light within the resident's reach. CNA 1 stated she should have placed the call light within the resident's reach after providing ADL care to the resident. During an interview on 10/20/2023 at 10 a.m., the DON stated call lights should always be within the resident's easy reach for staff to be able to respond to residents' needs and requests. c. A review of Resident 51's Record of admission indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of Resident 51's MDS, dated [DATE], indicated Resident 51 was comatose (a period of prolonged unconsciousness brought on by illness or injury). A review of Resident 51's Care Plan, dated 10/20/2023, indicated Resident 51 has a potential for falls and injury related to balance deficit and unable to balance self when turned to sides. The care plan further indicated the approach plan included placing the call light within reach. During an observation, on 10/16/2023, at 10:30 a.m., inside Resident 51's room, the resident's call light was observed hanging from the resident's bed, out of the resident's reach. During an interview with the DSD, on 10/20/2023, at 8:57 a.m., the DSD stated call lights should be within the resident's reach, regardless of whether the resident has the ability to use the call light or not. The DSD stated it is important to have the call light within reach so that residents are able to call for help. The DSD further stated if residents are not able to call for help, there could be a delay in care for the residents. During an interview with the DON, on 10/20/2023, at 12:05 p.m., the DON stated call lights should be placed within a resident's reach. The DON further stated if the call light is not within reach, the facility staff would not be able to attend to the needs of the resident, it can delay the residents' care, and it can increase the potential for falls among residents. A review of the facility's policy and procedure (P&P) titled, Call Lights, reviewed 1/26/2023, indicated all residents on the adult unit have a working call light to enable them to call for assistance. The P&P further indicated the call light will be placed within their reach and will be monitored for positioning by Licensed Nurses and Certified Nursing Assistants during rounds and after treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, comfortable, and homelike environment to three out of 52 sampled residents (Residents 32, 16, and 81) by: 1. Failing to ensure Resident 32's bed remote control with exposed wires was replaced. 2. Failing to ensure Resident 16's call light button with loose electrical tape on the electrical cord was replaced. 3. Failing to ensure Resident 81's electric fan was dust-free. These deficient practices had the potential to result in accidental injury, residents not being to call for help, affect the comfort of residents and increase the risk of infection. Findings: a. A review of Resident 32's admission Record indicated the facility admitted Resident 32 on 9/28/2010 and readmitted the resident on 11/10/2010, with diagnoses including severe intellectual disabilities (a term used when there are limits to a person's ability to learn at an expected level and function in daily life), irritability, and anger, and tracheostomy (an opening surgically created through the neck into the trachea [wind pipe] to allow air to fill the lungs). A review of Resident 32's History and Physical (H&P), dated 10/3/2023, indicated the resident was alert, verbal, and social with cognitive developmental delays (a term used when a person has certain limitations in mental functioning and in skills such as communicating, taking care of him or herself, and social skills), walks with altered gait (a manner of walking or moving on foot), and difficult to redirect. A review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/7/2023, indicated Resident 32 usually makes self-understood and understand others. During a concurrent observation and interview on 10/16/2023, at 11:06 a.m., with Licensed Vocational Nurse 4 (LVN 4), observed resident's bed remote control with exposed wires. LVN 4 stated the exposed wires on the bed remote control is dangerous to residents and staff. During an interview on 10/18/2023, at 9:16 a.m., the Maintenance Supervisor (MS) stated the bed remote control should be replaced and immediately removed. The MS stated the staff should have reported the defective electrical devices so it can be replaced. The exposed wires can be a hazard to residents and staff because it may cause electrocution. During an interview on 10/20/2023, at 8:40 a.m., the Director of Staff Development (DSD) stated the staff should have removed the bed remote control with the frayed wires immediately and have the maintenance staff replaced it right away. The DSD stated the defective remote could cause fire and had the potential for the resident to touch it and hurt themselves. During an interview on 10/20/2023, at 9:36 a.m., the Director of Nursing (DON) stated the staff should have reported the defective bed remote control to the maintenance staff so it can be replaced. The DON stated having a bed remote control with exposed wires had the potential for the resident not being able to adjust the bed which may cause the resident discomfort. A review of the facility's recent policy and procedure titled, Electrical Appliances, last reviewed on 4/27/2023, should electrical appliances be permitted, each must be in good working order, free of frayed cords, and Underwriter Laboratories (UL, are most widely known for standards in electrical products) approved. A review of the facility's recent policy and procedure titled, Quality of Life- Homelike Environment, last reviewed on 1/26/2023, indicated residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. b. A review of Resident 16's admission Record indicated the facility admitted Resident 16 on 5/10/2019, with diagnoses including disorder of psychological development (impairments in a child's physical, cognitive, language, or behavioral development), intracranial injury (brain swelling inside the confined area of the skull because of the injury), and legal blindness. A review of Resident 16's H&P, dated 5/6/2023, indicated Resident 16 did not have the capacity to understand and make decisions. A review of Resident 16's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS also indicated the resident was severely visually impaired. During a concurrent observation and interview on 10/16/2023, at 9:58 a.m., with Licensed Vocational Nurse 5 (LVN 5), observed Resident 16's call light cord with loosely applied electrical tape covering the exposed wires. LVN 5 stated the electrical tape covering the exposed wires of the call light cord was loose. LVN 5 stated the call light should be in good working condition. A review of the facility's recent policy and procedure titled, Electrical Safety for Residents, last reviewed on 3/2023, indicated the resident will be protected from injury associated with the use of electrical devices, including electrocution, burns, and fire. Inspect electrical outlets, power strips, and electrical devices as part of routine fire safety and maintenance inspections. A review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, reviewed 1/26/2023, indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P further indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including personalized furniture and room arrangements to the extent possible. c. A review of Resident 81's Record of admission indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic respiratory failure and encounter for attention to tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing). A review of Resident 81's MDS, dated [DATE], indicated Resident 81 was comatose (a period of prolonged unconsciousness brought on by illness or injury) and receives respiratory treatments including oxygen therapy, suctioning, and tracheostomy care. During an observation on 10/16/2023, at 9:45 a.m., inside Resident 81's room, an electric fan in the corner of Resident 81's room had dust on the surface of the screen pointing toward the resident. Further observation indicated the electric fan was on and blowing air towards Resident 81. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 12, on 10/18/2023, at 8:14 a.m., inside Resident 81's room, LVN 12 confirmed the presence of dust on Resident 81's electric fan. LVN 12 stated there should not be any dust on the electric fan. LVN 12 stated the facility does not want residents to inhale dust. LVN 12 further stated if residents inhale dust, it can cause respiratory issues with the residents. During a concurrent observation and interview with Registered Nurse (RN) 10, on 10/18/2023, at 8:38 a.m., inside Resident 81's room, RN 10 confirmed the presence of dust on Resident 81's electric fan. RN 10 stated there should not be any dust on the fan. RN 10 further stated it is important to keep the electric fan clean to prevent respiratory complications with the resident. During an interview with the DSD, on 10/20/2023, at 8:57 a.m., the DSD stated electric fans should be kept clean. The DSD stated if the electric fan is blowing dirty air, it could be a potential for infection and allergies. The DSD further stated it is important to keep the electric fans clean because the residents have tracheostomies and they already have a compromised respiratory system. During an interview with the DON, on 10/20/2023, at 12:05 p.m., the DON stated there should not be any dust on the electric fan and housekeeping needs to monitor it and keep it clean at all times. The DON stated signage on the electric fan to not turn off the fan is not an excuse to not clean the fan. The DON further stated if the electric fan is not kept clean, residents can possibly inhale the dust and can increase the risk for infection. A review of the facility's P&P titled, Housekeeping: Equipment Cleaning, reviewed 1/26/2023, indicated personnel will clean equipment for optimal prevention of infection. The P&P further indicated fans should be cleaned with germicidal wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces and skin).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b.1. A review of Resident 47's admission Record indicated the facility admitted Resident 76 on 12/03/2015 and readmitted the resident on 03/15/2023 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), hypoxic ischemic encephalopathy ([NAME] - a type of brain damage caused by a lack of oxygen before or shortly after birth), and convulsions (rapid, involutory muscle contractions that cause uncontrollable shaking and limb movement). A review of Resident 47's MDS, dated [DATE], indicated Resident 47 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff for dressing, feeding, personal hygiene, and all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 47's Order Summary Report indicated an order, dated 3/15/2023, for: - Check low air loss mattress pressure every shift as per resident's weight for skin management. During a concurrent observation and interview on 10/16/2023 at 10:17 a.m. with Licensed Vocational Nurse 11 (LVN 11), observed Resident 47 on a low air loss mattress set at 400 pounds (lbs.- unit of measurement of weight). LVN 11 stated based on the resident's weight of 80 lbs., the mattress did not have the correct setting. LVN 11 stated the low air loss mattress is used to prevent pressure injuries (areas of skin that are damaged after being compressed for too long). b.2. A review of Resident 76's admission Record indicated that the facility admitted Resident 76 on 12/10/2023 with diagnoses including chronic respiratory failure with hypercapnia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and spastic quadriplegic cerebral palsy (CP - a condition that is caused by abnormal brain development that affects a person's ability to control their muscles). A review of Resident 76's MDS, dated [DATE], indicated Resident 76 had severely impaired cognition and was totally dependent on staff for dressing, feeding, personal hygiene, and all other activities of daily living. A review of Resident 76's Order Summary Report indicated an order, dated 2/3/2021, of: - Every shift, check that the low air loss mattress pressure is at 80-160 per the resident's weight of 102.96 pounds for skin management. During a concurrent observation and interview on 10/16/2023 at 2:26p.m., with LVN 15, observed Resident 76, on a low air loss mattress set at 400 lbs. LVN 15 stated she needed to check the physician order for the LAL mattress setting. LVN 15 returned to Resident 76's room with RN 11. RN 11 stated that the correct setting for Resident 76's low air loss mattress is 100, based on the resident's weight and as indicated in the physician order. LVN 15 stated that the low air loss mattress is used to prevent pressure injuries. During a concurrent interview and record review on 10/19/2023 at 9:49 a.m., with Registered Nurse 8 (RN 8), Resident 47 and Resident 76's medical records including care plans were reviewed. RN 8 stated both Resident 47 and Resident 76 are on the skin management program. RN 8 stated Residents 47 and 76 did not have a care plan addressing the use of low air loss mattress. RN 8 stated that it was important to have care plans for the use of the low air loss mattress to maintain the residents' skin integrity. During an interview on 10/20/2023 at 9:09 a.m., the Director of Staff Development (DSD) stated that it is important to have a care plan to ensure the necessary care and services to prevent the development of pressure ulcers are being provided to the residents. During an interview on 10/5/2023 at 3:08 p.m., the DON stated care plans for the use of low air loss mattress care plans should be developed for both Resident 46 and Resident 76 to provide direction of care to maintain the residents' skin integrity. A review of the facility's recent policy and procedure titled Pressure Sore Prevention and Management, last reviewed on 1/26/2023, indicated: Care Plan initiated upon admission and/or upon identification of high-risk Residents. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of six sampled residents (Resident 1, 47, and 76), by failing to: 1. Develop an accurate care plan addressing placement of bed rails for Resident 1. 2. Develop a care plan addressing the use of a physician ordered low air loss mattress (LALM, is a medical device that helps prevent pressure ulcers [bed sores] by providing constant airflow to keep the skin cool and dry) for Residents 47 and 76. These deficient practices had the potential to result in the delay of necessary care and services. Findings: a. A review of Resident 1's Record of admission indicated the facility readmitted the resident on 2/26/2018 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), encounter for attention to gastrostomy (a surgical procedure used to insert a tube, often referred to as a g-tube, through the abdomen and into the stomach), and gastro-esophageal reflux disease (GERD, a condition in which the stomach contents leak backward from the stomach into the esophagus). A review of Resident 1's History and Physical, dated 2/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/14/2023, indicated the resident required total dependence with bed mobility, dressing, and eating with physical assist from staff. A review of Resident 1's Physician Orders, dated 2/26/2018, indicated an order for: -Side rails up due to non-restraint due to ADLs and mobility. During an observation on 10/16/2023 at 2:23 p.m., observed Resident 1 in bed, with all four (x4) side rails up. During a concurrent observation and interview on 10/17/2023 at 11:37 a.m., with Certified Nursing Assistant 6 (CNA 6), observed Resident 1 in bed, with all four (x4) side rails up. CNA 6 stated the resident's four side rails are always up and are rarely lowered down. During a concurrent interview and record review with the MDSC on 10/17/2023 at 4:50 p.m., Resident 1's bed rail assessment and care plans were reviewed and indicated the following: - Care plan titled potential for falls/ injuries, dated 2/20/2023, with an intervention to place side rails up x2 when in bed, 8/2023. - Care plan titled, Potential for seizure activity, with an intervention to place side rails x2 when in bed, with reevaluation date of 8/2023. - Bed rail assessment, dated 2/20/23, full rails. Reassess side rails annually, last evaluation on 8/4/2023, side rails up for safety due to poor balance, visual check 1-2 hours. The MDSC stated Resident 1's care plans should have indicated the resident required all four side rails up as indicated in the bed rail assessment done by the interdisciplinary team (IDT, a conduct the person-centered services planning and participates in ongoing care management activities) During an interview on 10/20/2023 at 4:30 p.m., the Director of Nursing (DON) stated the resident care plans should be updated to indicate the physician orders for the use of side rails. The DON stated Resident 1's care plans should have indicated the appropriate number of side rails needed. A review of the facility's policy and procedure (P&P) titled, Resident/Patient Care Plans, last reviewed and approved on 1/26/2023, indicated outcome identification will be individualized to the resident and realistic. The P&P indicated the plans of care will be individualizes to the resident's condition or needs and the nursing staff will implement the interventions identified in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure professional standards were met by 3 of 5 Licensed Vocational Nurses (LVNs 1, 2, and 3) affecting three of five sampled residents (Resident 22, 43, and 68) investigated during Medication Administration task. The facility failed to: 1a. Ensure LVN 1 read the medicine label and compare with the Medication Administration Record (MAR) to ensure Resident 22 received the correct dose of Potassium chloride (KCl, medicine used to prevent or treat low potassium levels in the body; potassium is a mineral the body needs for proper functioning of several organs including the heart) through Resident 22's gastrostomy tube (GT, a soft tube inserted during surgery into the stomach through the belly to deliver food and medications on a person unable to swallow), as ordered by the physician. 1b. Ensure LVN 1 clarified the order of Colace to give to Resident 22 through the GT and not attempt to place a capsule in hot water following standard of practice. 1c. Ensure LVN 1 did not mix three of eight medications for administration through Resident 22's GT, following the facility's P&P on Medication Pass to give medications one at a time. 2a. Failing to administer 50 milliliters (ml, a unit of measurement) of water into Resident 43's GT, prior to medication administration as ordered by the physician. 2b. Failing to administer Resident 43's medication and water flushes via gravity (a method of medication administration that uses gravity to pull medication from a piston syringe [a calibrated hollow barrel and a movable plunger used to administer medications and/or water through a GT] in a downward direction through a GT), as indicated in the facility's P&P on Medication Pass via (through) GT. 2c. Failing to administer 5 ml to 10 ml of water to Resident 43's GT between each medication administered, as ordered by the physician and facility's P&P. 3. Ensure LVN 3 administered Resident 68 the complete dose of three of six crushed medications via GT and did not leave significant residues of undissolved medications in the medication cup (plastic translucent cup suitable for dispensing both liquid and dry medications, calibrated from 2.5 ml to 30 ml) in accordance with the physician's orders and professional standard of practice. These deficient practices of administering medications without following physicians' orders, P&Ps, and professional standards of practice placed Resident 22, 43, and 68 at risk of health complications. Cross reference F755, F759 and F760 Findings: 1. A review of Resident 22's admission Record indicated the facility admitted the resident on 11/6/2008 with a readmission dated 5/23/2014. Resident 22's diagnoses included seizure (convulsions) disorder, chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [waste gas made in the body's cells]), dependence on respirator (or ventilator, a machine that helps persons that cannot breathe on their own), tracheostomy (a medical procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and GT. A review of Resident 22's History and Physical (H&P) exam, dated 5/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 8/29/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks such as eating, walking, dressing, bathing, moving in bed, toilet use, and personal hygiene). A review of the Physician's Orders for Resident 22 indicated the following medications: - Keppra (antiseizure medication) 1500 milligrams (mg - a unit of measurement) via GT every 12 hours for seizure disorder ordered on 7/22/2018. - Dilantin (antiseizure medication) 250 mg via GT every 12 hours for seizure disorder, hold GT feeding one hour before and after medication administration, ordered on 10/4/2023. - KCl 20 milliequivalent (mEq - a unit of measurement) 15 ml via GT, dilute with 200 ml water, give daily as supplement, ordered on 7/5/2023. - Colace 250 mg via GT every 12 hours for bowel management, hold for diarrhea, ordered on 4/18/2022. On 10/18/2023 at 8:11 a.m., during a medication administration observation, review of Resident 22's MAR indicated there were eight medications to administer to Resident 22 including the following four medications that LVN 1 prepared: - 15 ml of Keppra and placed it in a medicine cup. - 10 ml of Dilantin and placed it in another medicine cup. - 15 ml of KCL 20 MEQ diluted with 200 ml water in a Styrofoam cup. - One softgel capsule (suited for liquid or semi-solid fillings) of Colace 250 mg 1a. During a medication administration observation on 10/18/2023 at 8:11 a.m., LVN 1 pulled out the bottle of KCl oral solution labeled with Resident 22's name from the medication cart. LVN 1 stated the MAR indicated to administer KCl 20 mEq. Observed the prescription label in the medication bottle indicated KCL 40 mEq (30 ml) via GT daily, dilute with 200 ml water. The label fill date was 9/22/2023. LVN 1 attempted to pour the KCL into a small medicine cup without verifying the dosage in the bottle. During a concurrent observation, interview, and record review on 10/18/2023 at 8:20 a.m., the MAR and KCl bottle label were reviewed with LVN 1 who verified the medication bottle label indicated KCL 40 mEq (30 ml) via GT daily dilute with 200 ml water with a fill date of 9/22/2023. LVN 1 stated the MAR indicated KCl 20 MEQ (15 ml) via GT dilute with 200 ml water daily for supplement. LVN 1 verified the prescription label in the KCl bottle, and the MAR did not match. LVN 1 stated if the label and the MAR did not match, she will notify the charge nurse and check the physician's order. LVN 1 stated LNs were supposed to follow the ten (10) rights of medication administration which included to read the medication label and compare it with the MAR. During a concurrent interview with RN 5 and record review on 10/18/2023 at 8:42 a.m., reviewed the MAR and the prescription label for KCl, RN 5 stated if the label and the MAR did not match, she will check the physician's order and attach a Directions Changed Refer to Chart sticker. RN 5 verified there was no sticker on the medication bottle. LVN 1 and RN 5 stated it was important that the prescription label matched the physician's order and the MAR to ensure Resident 22 received the proper dosage of the medication. 1b. Continuing with the medication administration observation on 10/18/2023 at 8:40 a.m., LVN 1 dispensed Colace 250 mg softgel capsule from a medication bottle into a medicine cup and set it aside. LVN 1 stated the bottle of Colace was a house supply and she was going to place the Colace softgel capsule in hot water to melt the medication. During a concurrent observation, interview, and record review on 10/18/2023 at 8:45 a.m., the MAR and the medication bottle were reviewed with RN 5, who stated the order did not specify the form of the medication (liquid, table, capsule, etc.) to be administered to Resident 22. RN 5 stated the physician should have been notified to clarify the Colace in a liquid form. RN 5 stated if the softgel was placed in hot water, it had the potential to lose the medication potency or efficacy. 1c. During a concurrent observation and interview on 10/18/2023 at 9:05 a.m., LVN 1 added to the Styrofoam cup (with the KCl), the Keppra and the Dilantin and administered to Resident 22 through the GT. When asked, LVN 1 stated and verified that she poured the Dilantin and Keppra into the Styrofoam cup with the KCl diluted in 200 ml of water and administered them together via the GT. LVN 1 stated that she was trained this way on administration of medications to residents with GT but said she should have administered each medication one at a time. LVN 1 stated the medications may not be compatible and mixing them may result on adverse drug reaction placing Resident 22 at risk for serious medical complications. During an interview on 10/18/2023 at 3:00 p.m., LVN 1 stated she failed to follow the facility's P&P and standard of practice by mixing medications instead of giving Resident 22 one medication at a time. LVN 1 stated that she was nervous, and it was her first time a surveyor followed her during medication administration. On 10/19/2023 at 9:21 a.m., the Director of Staff Development (DSD) stated that newly hired LVNs without experience were trained on administering medications and GT administration for seven 12-hour shifts under the guidance of an experienced LN and LVN 1 was signed off as competent on 4/13/2023. The DSD stated the medication administration part on the Competency Orientation Training Checklist and RN/LVN Annual Skills Checklist did not specify competency for medication administration through GT. The DSD stated the Director of Nursing (DON) conducts the LNs annual performance evaluations on the anniversary of the LN date of hire. During an interview on 10/20/2023 at 8:00 a.m., the DON stated medications for GT administration should be given one at a time, to ensure there were no physical or chemical incompatibilities between medications and avoid placing the residents at risk for serious medical complications that may lead to hospitalization or death. The DON stated liquid medications should be administered directly into the GT unless there was a physician's order to dilute with water. The DON stated the prescription label for the KCl should match the MAR and the physician's order unless there was a change of direction. The DON stated the physician should be notified and obtain an order to change the Colace softgel capsule to liquid form for appropriateness during medication administration via GT. The DON stated that placing the softgel in hot water was not acceptable as the medication can lose its potency or efficacy. A review of the facility's P&P titled, Medication Labeling, last reviewed on 1/26/2023, indicated the following: - Prescription medication will have the following information on the label: a. Name, strength, and quantity of drug b. Dose c. Expiration date - If an order is changed on a prescription medication, a Directions changed refer to chart sticker will be placed on medication with the change. A review of the facility's P&P on Medication Pass via GT /Jejunostomy tube (JT, a soft tube inserted during surgery into the small intestine [bowel] through the belly to deliver food and medications), last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to pass medications through the GT / JT. The policy indicated the following: - Follow the 10 Patient Rights of giving medications. - Give medications as ordered one at a time with 5 to 10 ml in between each medication or as per physician order. A review of the facility's P&P titled, Medication Pass, last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to properly complete medication pass. The policy indicated: - Follow the 10 Patient Rights of giving medications. - Check medication against the MAR to be correct. - Give medication one at a time. A review of the facility's P&P policy and procedure titled, 10 Medication Rights, last reviewed on 1/26/2023, indicated as policy statement to make sure the LNs follow the updated guidelines for the patient medication rights. The policy indicated to read the medication label carefully and compare it to the MAR. If there are any doubts, verify with the chart and the Charge Nurse (CN). 2. A review of Resident 43's admission Record indicated the facility originally admitted the resident on 9/7/2016 with diagnoses including chronic respiratory failure, GT, anoxic brain damage (injuries caused by a complete lack of oxygen to the brain, which results in the death of brain cells), acute embolism (obstruction of an artery [type of blood vessel], typically by a clot of blood or an air bubble), and thrombosis (local clotting of the blood in a part of the circulatory system [system that circulates blood through the body: the heart, blood vessels, and blood]). A review of Resident 43's MDS, dated [DATE], indicated Resident 43 rarely or never understood, was unable to make decisions, and required total staff assistance with ADLs. A review of the Physician's Order for Resident 43, indicated the following: - Flush 50 ml of water via GT before and after medication administration and 5 ml to 10 ml in between medications, ordered on 9/9/2016. - Vitamin D 1000 international units (IU - a unit of measurement) via GT every day for supplement, ordered on 1/19/2018. - Tums (medication used to relieve heartburn) 750 mg per tablet, one tablet via GT every 12 hours, ordered on 8/14/2018. - Multivitamins with minerals one tablet via GT every day for supplement, ordered on 4/15/2019. - Vitamin C 500 mg via GT every 12 hours for supplement, ordered on 7/25/2019. - Xarelto (rivaroxaban, blood thinner to treat and prevent blood clots) 10 mg via GT every day to prevent for deep vein thrombosis (DVT - a blood clot in a deep vein, usually in the legs), dated 9/23/2019. On 10/18/2023, at 9:04 a.m. during a medication administration observation and concurrent interview, LVN 2 was outside Resident 43's room reviewing Resident 43's medication administration record (MAR). LVN 2 stated Resident 43 was going to receive the following medications through the GT: - Tums 750 mg - Vitamin D 1000 IU - Multivitamins with minerals one tab - Vitamin C 500 mg - Xarelto 10 mg LVN 2 placed each medication in a medication cup, then proceeded to transfer each medication into separate clear packets and crushed each one using a pill grinder. Then, placed the crushed contents of each packet into separate medicine cups. On 10/18/2023, at 9:20 a.m., continuing with the medication pass observation at bedside, LVN 2 used a piston syringe poured approximately 5 ml to 10 ml of water into five small clear plastic cups containing crushed medications and mixed the contents of each cup separately. 2a. LVN 2 did not administer 50 ml of water through Resident 43's GT as ordered by the physician. 2b. LVN 2 drew up the mixture from one of the five cups using the piston syringe, connected the piston syringe barrel to the GT, and slowly pushed the medication using the syringe plunger instead of allowing the medication. LVN 2 continued to give the remaining four medications and slowly pushing each medication, not following standards of practice and P&P. 2c. LVN 2 continue did not administer 5 ml to 10 ml of water into Resident 43's GT between each medication administered as per physician's order and P&P. On 10/18/2023, at 9:26 a.m., after completing the medication pass, a concurrent interview with LVN 2 and a review of Resident 43's MAR which indicated to flush 50 ml of water via GT before and after medication administration and 5 ml to 10 ml in between medications. LVN 2 stated she forgot to flush Resident 43's GT with 50 ml of water before administering the medications and confirmed not flushing the GT with 5 ml to 10 ml between the five medications. LVN 2 stated it was important to flush a GT prior to administering medications to check for patency (open or unobstructed) and to prevent clogging. LVN 2 explained that since she had a lot of medications to administer, she did not want to take time in flushing water between each medication. LVN 2 stated she sometimes administers water between each medication, but only if the medication is sticky. LVN 2 stated it is important to administer water between each medication to prevent the medications from clogging the GT. Further review of Resident 43's MAR did not indicate Resident 43 had an order for gentle pushes to administer medications and was confirmed by LVN 2. LVN 2 stated she did not administer Resident 43's medication by gravity. During an interview, on 10/20/2023, at 12:05 p.m., the DON stated that prior to medication administration, the nurses needed to review the resident's MAR for instructions on which medications needed to be administered and how the medications were to be administered. The DON stated the GT needed to be flushed with 50 ml of water prior to medication administration and medications needed to be administered one at a time, by gravity. The DON stated it was not appropriate to push medications into the GT with the piston syringe because it could result on the medications splash if the GT dislodged from the syringe or the resident may aspirate (liquid go into the airway) if the medication was pushed fast. The DON stated 5 ml to 10 ml of water is needed to be flushed between each medication to make sure there were no drug interactions and to prevent the GT from clogging. On 10/20/2023, at 4:55 p.m., during an interview, the Medical Director (MD) stated flushing the GT with water before, between, and after medication administration was a standard practice. The MD stated administering water is done to make sure the medication is distributed properly, if water is not flushed between each medication, it was possible residual medication (in the tubing) would not reach its destination. A review of the facility's P&P titled, Gastrostomy Tube Water Flush, reviewed 1/26/2023, indicated the procedure for water flush: - Insert syringe into the end of the GT - Pour water into syringe - Allow water to flow by gravity into stomach - Hold about 12-18 inches (unit of measurement) above the opening - Flush 50 ml prior to medication administration, then flush 5 ml to 10 ml between each medication or per physician's order. A review of the facility's P&P on Medication Pass Via GT / JT, reviewed on 1/26/2023, indicated to flush the tube as ordered before and after medication administration. The P&P further indicated adults are given medications as ordered one at a time with 5 ml to 10 ml in between each medication or as per physician's orders. 3. A review of Resident 68's admission Record indicated the facility admitted the resident on 10/28/2019 with diagnoses including anoxic brain damage, tracheostomy, and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 68's H&P exam, dated 3/1/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 68's MDS, dated [DATE], indicated the resident had severely impaired cognition, had a GT for feeding, and was dependent on staff with all ALDs. A review of the Physician's Orders for Resident 68 indicated the following medications: - Colace (stool softener) 100 mg via GT, every 12 hours for bowel management, hold for loose stool, ordered on 4/26/2023. - Glycopyrrolate (Robinul, anticholinergic medication) 2 mg via GT, every 8 hours for secretions, ordered on 3/1/2023. - Magnesium oxide (mineral supplement used to prevent and treat low amounts of magnesium in the blood) 400 mg via GT every day, ordered on 3/1/2023. - Vitamin D 2000 IU via GT every day for supplement ordered on 3/1/2023. - Clonidine (to treat hypertension) 0.2 mg via GT twice a day ordered on 3/1/2023. - Tizanidine (Zanaflex, muscle relaxant) 2 mg via GT three times a day ordered on 3/1/2023. A review of Resident 68's Care Plan developed on 4/17/2023 for the resident's excessive (respiratory) secretions requiring Robinul every 8 hours, had a goal for the resident to always have patent (unobstructed) airway. The interventions included to give medications as ordered. On 10/18/2023, at 8:14 a.m. during a medication administration observation LVN 3 prepared Resident 68's morning medications, as follows: - Colace 100 mg, 1 tablet - Robinul 2 mg, 1 tablet - Magnesium oxide 400 mg, 1 tablet - Vitamin D3 1000 IU, 1 tablet - Clonidine 0.2 mg, 1 tablet - Zanaflex 2mg 1 tablet At 8:18 a.m., LVN 3 crushed each tablet in a separate plastic packet and placed each crushed medication into separate medicine cups. At 8:23 a.m., LVN 3 placed medicine tray with the six medication cups on top of overbed side table and poured about 10 ml of water inside each medicine cup. At 8:27 a.m., LVN 3 attached the piston syringe hollow barrel to the GT and removed the syringe plunger before administering the medications. LVN 3 shook each medicine cup before pouring each content in the syringe barrel allowing the content to go through the GT by gravity. At 8:36 a.m., during an interview, LVN 3 stated she completed medication pass for Resident 68. There were three medicine cups with residual crushed medications. LVN 3 stated the cups contained Vitamin D, magnesium oxide, and Robinul. LVN 3 stated some of the crushed tablets stuck to the bottom of the cup. LVN 3 stated she did not know how much of the medicine was left in the three medicine cups, but it seemed a lot. LVN 3 stated she was going to dispose of them. At 8:38 a.m., LVN 3 proceeded to sign Resident 68's MAR indicating the six medications were given. During an interview on 10/20/2023 at 4:06 p.m., the DON stated that after administering medication, the LNs must check the medicine cup to ensure there is no medication remaining and the residents receive the ordered dose. The DON stated LNs may use apple sauce so the crushed medications would not stick on the bottom of the medicine cup and may use a spoon or a coffee stirrer to stir the medication. The DON stated Resident 68 did not receive the ordered dose of Robinul and it was possible for Resident 68 to have increased respiratory secretions, which may lead to respiratory distress, coughing, or aspiration. On 10/20/2023 at 4:55 p.m., during an interview, the MD stated sometimes anticholinergic medications are given due to the excess secretion or for bradycardia (slow heart rate). The MD stated when anticholinergics are not administered correctly the resident may need to be suctioned (removal of secretions from the airway using a suction machine). A review of the facility's policy and procedure titled, Medication Rights, reviewed and approved 1/26/2023, indicated it is the facility's policy to make sure that licensed nurses follow the updated guidelines for the Patient Medication Rights. The procedure indicated: 3. Right Dose - compare the dose of the medication to the MAR. 6. Right Documentation - the documentation of the medication must be done at the time that you give the medications. A review of the facility's policy and procedure on Medication Pass via GT / JT, reviewed on 1/26/2023, indicated it was the facility's policy to make sure that nursing would follow the policy of giving medications. The procedures indicated to ensure all medication is given and not remaining in the cup.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 61's admission Record indicated that the facility admitted the resident on 8/16/2016 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), chronic atrial fibrillation (A Fib- an irregular and often very rapid heart rhythm), and type 2 diabetes mellitus (a disease that occurs when your blood glucose is too high). A review of Resident 61's History and Physical, dated 9/14/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 61's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/21/2023, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding) and needed extensive assistance for bed mobility, bed transfer and dressing, as well as one-to- two persons assistance with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation and interview on 10/18/2022 at 1 p.m. with Licensed Vocational Nurse 14 (LVN 14), LVN 14 stated the resident did not have an identification band after he administered medication to the resident. During an interview on 11/8/2022 at 1:31 p.m. with Registered Nurse 10 (RN 10), RN 10 stated that the resident should have an identification band to confirm the resident's identity. During an interview on 10/20/2023 at 9:19 a.m., the Director of Staff Development (DSD) stated all residents need to have an identification band so the licensed nurses can verify the resident's name on the band before administering any medication. The DSD stated not placing an identification band on residents had the potential to result in medication error. During an interview on 10/5/2023 at 3:08 p.m., the Director of Nursing (DON) stated all residents need to have an identification band to identify the residents and to ensure they receive the correct medication and treatment. A review of the recent facility policy and procedure titled Resident Identification Band, dated 1/26/2023, indicated: All newly admitted and readmitted residents will be provided with an identification band. Based on observation, interview, and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice to three out of three sampled residents (Resident 54, Resident 5, and Resident 61) by: 1. Failing to ensure Resident 54 and Resident 5 sequential compression device (SCD, a method of deep vein thrombosis [DVT, occurs when a blood clot forms in one or more deep veins in the body, usually in the legs] prevention that improves blood flow in the legs) to bilateral lower extremities was on. The deficient practice had the potential for residents to develop deep vein thrombosis (DVT). 2. Failing to ensure Resident 61 had an identification band. This deficient practice created the potential for misidentification of the Resident 61, which could lead to medication error. Findings: a. A review of Resident 54's admission Record indicated the facility admitted Resident 54 on 1/4/2017 and readmitted the resident on 1/26/2023, with diagnoses including, quadriplegia (a form of paralysis that affects all four limbs, plus the torso), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). A review of Resident 54's History and Physical, dated 1/27/2023, indicated Resident 54 did not have the capacity to understand and make decisions. A review of Resident 54's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/11/2023, indicated Resident 54 rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 54 required total dependence on bed mobility, dressing, eating, toilet use, and personal hygiene with one to two-persons assist. A review of Resident 54's Physician's Orders, dated 1/26/2023, indicated an order for Resident 54 to have SCD to bilateral lower extremities at all times, remove leg wraps every (q) 12 hours. Check and assess skin integrity and if necessary (prn) (DVT prophylaxis [measures designed to preserve health and prevent the spread of disease]). A review of Resident 54's Care Plan, last evaluated on 8/2023, indicated Resident 54 requires SCD boots for DVT Prophylaxis. During a concurrent observation and interview on 10/16/2023, at 10:15 a.m., with LVN 5, Resident 5's SCD was not turned on. LVN 5 stated the SCDs should be on to prevent DVT. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 5/2/2019 and readmitted the resident on 6/9/2019, with diagnoses including spastic quadriplegic cerebral palsy (a form of cerebral palsy [weakness or problems with using the muscles] that affects both arms, legs, often the torso, and face), dependence on respirator (a device that forces air into a person's lungs when the person cannot breathe independently and needs help to breathe), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of Resident 5's H&P, dated 6/1/2023, indicated Resident 5 did not have the capacity to understand and make decisions. A review of Resident 5's MDS, dated [DATE], indicated Resident 5 rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 5 required total dependence on bed mobility, dressing, eating, toilet use, and personal hygiene with one to two-persons assist. A review of Resident 5's Physician's Orders, dated 1/24/2020, indicated an order for Resident 5 to have SCD to bilateral lower extremities at all times remove leg wraps and check and assess skin integrity q 12h and prn (DVT prophylaxis). A review of Resident 5's Care Plan, last evaluated on 8/2023, indicated Resident 5 requires SCD boots for DVT Prophylaxis. During a concurrent observation and interview on 10/16/2023, at 10:15 a.m., with LVN 5, observed Resident 5's SCD was not turned on. LVN 5 stated the SCDs should be on to prevent DVT. During an interview on 10/20/2023, at 8:40 a.m., the Director of Staff Development (DSD) stated the purpose of the SCD is to prevent DVT. The DSD stated most of their residents are immobile, and the only way they could get blood flow to the residents' legs was through the SCD. The DSD stated the not having the SCD powered on may place the residents at risk for DVT. During an interview on 10/20/2023, at 9:36 a.m., the Director of Nursing (DON) stated the staff should always make sure to keep the SCDs on to prevent embolism (a blocked artery caused by a foreign body, such as a blood clot or an air bubble), DVT, and to promote circulation. A review of the facility's recent policy and procedure titled, Sequential Compression Device, last reviewed on 1/26/2023, indicated sequential compression device is used to limit the development of deep vein thrombosis and/or prevent blood clot formation. Nursing will check on the device and assess resident 9 am, and 9pm. Nursing will apply the device as per MD's orders. A review of the Flowtron Excel (External Pneumatic Compression System for DVT Prophylaxis) Operating Instructions Model AC550, dated 1994, indicated Flowtron Excel is non-invasive prophylactic system for reducing the incidence of deep vein thrombosis (DVT). The application of external pneumatic compression has two effects: 1. Augments venous blood flow velocity, thereby reducing stasis, and 2. Enhances fibrinolytic activity to reduce the risk of early clot formation. Under Cautions . 1. Proper application and connection and connection to the pump is essential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.a. A review of Resident 47's admission Record indicated the facility admitted Resident 76 on 12/03/2015 and readmitted the resident on 03/15/2023 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), hypoxic ischemic encephalopathy ([NAME] - a type of brain damage caused by a lack of oxygen before or shortly after birth), and convulsions (rapid, involutory muscle contractions that cause uncontrollable shaking and limb movement). A review of Resident 47's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/15/2023, indicated Resident 47 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff for dressing, feeding, personal hygiene, and all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 47's Order Summary Report indicated an order, dated 3/15/2023, for: - Check low air loss mattress pressure every shift as per resident's weight for skin management. During a concurrent observation and interview on 10/16/2023 at 10:17 a.m. with Licensed Vocational Nurse 11 (LVN 11), observed Resident 47 on a low air loss mattress set at 400 pounds (lbs.- unit of measurement of weight). LVN 11 stated based on the resident's weight of 80 lbs., the mattress did not have the correct setting. LVN 11 stated the low air loss mattress is used to prevent pressure injuries (areas of skin that are damaged after being compressed for too long). 5.b. A review of Resident 76's admission Record indicated that the facility admitted Resident 76 on 12/10/2023 with diagnoses including chronic respiratory failure with hypercapnia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), spastic quadriplegic cerebral palsy (CP - a condition that is caused by abnormal brain development that affects a person's ability to control their muscles ), and dysphasia (swallowing difficulties). A review of Resident 76's Minimum Data Set, dated [DATE], indicated that Resident 76 had severely impaired cognition and was totally dependent on staff for dressing, feeding, personal hygiene, and all other activities of daily living. A review of Resident 76's Order Summary Report indicated an order, dated 2/3/2021, for: - Every shift, check that the low air loss mattress pressure is at 80-160 per the resident's weight of 102.96 pounds for skin management. During a concurrent observation and interview on 10/16/2023 at 2:26p.m., with LVN 15, observed Resident 76, on a low air loss mattress set at 400 lbs. LVN 15 stated she needed to check the physician order for the LAL mattress setting. During an interview on 10/6/2023 at 2:37p.m. with RN 11 and LVN 15, RN 11 stated that the correct setting for Resident 76's low air loss mattress is 100, based on the resident's weight and as indicated in the physician order. LVN 15 stated that the low air loss mattress is used to prevent pressure injuries. During a concurrent interview and record review on 10/19/2023 at 9:49 a.m., with Registered Nurse 8 (RN 8), Resident 47 and Resident 76's medical records including care plans were reviewed. RN 8 stated both Resident 47 and Resident 76 are on the skin management program. RN 8 stated Residents 47 and 76 did not have a care plan addressing the use of low air loss mattress. RN 8 stated that it was important to have care plans for the use of the low air loss mattress to maintain the residents' skin integrity. During an interview on 10/20/2023 at 9:09 a.m., the Director of Staff Development (DSD) stated that it is important to maintain the low air loss mattress setting according to residents' weight to prevent the development of pressure ulcers. During an interview on 10/5/2023 at 3:08 p.m., the Director of Nursing (DON) stated that the low air loss mattress setting has to be set according to the residents' weight to maintain the residents' skin integrity. A review of the facility's recent policy and procedure titled Low Air Loss Mattress, last reviewed on 1/26/2023, indicated: A Physician's order will be obtained for use of a Low Air loss Mattress. Based on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to eight out of 52 sampled residents (Residents 5, 113, 313, 18, 47, 76, 45, and 72) by: 1. Failing to ensure Resident 5's low air loss mattress (LALM, is a medical device that helps prevent pressure ulcers by providing constant airflow to keep the skin cool and dry) power was on. 2. Failing to ensure Resident 5, Resident 113, and Resident 313 was turned and repositioned every two hours. 3. Failing to ensure Resident 18's Treatment Record had proper documentation of when the treatment was performed as ordered by the physician. 4. Failing to ensure the residents' LALM were set according to the physician's order for Residents 313, 47, 76, 45, and 72. These deficient practices had the potential for development and worsening of pressure injuries to residents. Findings: 1. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 5/2/2019 and readmitted the resident on 6/9/2019, with diagnoses including spastic quadriplegic cerebral palsy (a form of cerebral palsy [weakness or problems with using the muscles] that affects both arms and legs and often the torso and face), dependence on respirator (a device for maintaining artificial respiration), and sepsis (a body's extreme response to an infection). A review of Resident 5's History and Physical (H&P), dated 6/1/2023, indicated Resident 5 did not have the capacity to understand and make decisions. A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/19/2023, indicated Resident 5 rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 5 required total dependence on bed mobility, dressing, eating, toilet use, and personal hygiene with one to two-persons assist. The MDS indicated the resident was always incontinent of urine and bowel (feces). The MDS indicated the resident was at risk for developing pressure ulcers/injuries and received skin and ulcer/injury treatments such as pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention, and application of nonsurgical dressings. A review of Resident 5's Assessment of Decubitus Ulcer Potential, dated 6/16/2023, indicated a risk score of 24 or high risk. A review of Resident 5's Physician Orders, dated 10/3/2023, indicated an order to check low air loss mattress every (q) shift set at 80 per resident's weight 74 pounds (lbs., a unit of weight) for skin management. A review of Resident 5's Care Plan, dated 6/16/2023, indicated Resident 5 had a potential for pressure ulcer development related to bed mobility problem with intervention to turn and reposition resident q 2 hours. A review of Resident 5's Adult Subacute Care 24 Hour Nursing Flow Sheet for 10/2023, indicated: On 10/12/2023, from 10 p.m. to 7 a.m. of 10/13/2023, resident was on his back. On 10/4/2023, from 7 a.m. to 7 a.m. of 10/5/2023, resident was on his back. On 10/2/2023, from 7 a.m. to 11 p.m. resident was on his back; 12 a.m. to 7 a.m. was on semi-Fowler's position (a standard patient position in which the patient is seated in a semi-sitting position [45-60 degrees] and may have knees either bent or straight). During a concurrent observation and interview on 10/16/2023, at 10:15 a.m., Licensed Vocational Nurse 5 (LVN 5), observed Resident 5's LALM off. LVN 5 stated she does not know how long the LALM was off for. LVN 5 stated the LALM's power should be kept on in order to prevent pressure ulcer. During an interview and record review on 10/18/2023, at 12:26 p.m., with Treatment Nurse 1 (TN 1) and Treatment Nurse 2 (TN 2), reviewed Resident 5's Adult Subacute Care 24-hour Nursing Flow Sheet for 10/2023. TN 1 and TN 2 stated there were multiple documented entries that indicated Resident 5 was not turned and repositioned every 2 hours. TN 1 and TN 2 stated the LALM's power should be kept on and Resident 5 should be turned every 2 hours to prevent development and worsening of a pressure injury. 2. a. A review of Resident 113's admission Record indicated the facility admitted Resident 113 on 5/14/2015 and facility readmitted the resident on 9/27/2023, with diagnoses including Guillain-Barre syndrome (a rare neurological disorder in which the immune system [the body's defense against infections] mistakenly attack part of the peripheral nervous system [a network of nerves that runs throughout the head, neck, and body), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes type 2 (the body does not make enough insulin [ a hormone that lowers the level of glucose [a type of sugar] in the blood or does not use insulin well). A review of Resident 113' H&P, dated 9/29/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 113's MDS, dated [DATE], indicated Resident 113 was dependent on all functional abilities. The MDS indicated Resident was incontinent of urine and stool. The MDS indicated Resident 113 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The MDS indicated Resident 113 had two stage 3 pressure ulcers (injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) and one stage 4 pressure ulcer (are deep wounds that may impact muscle, tendons, ligaments, and bone) that were present during admission/entry or reentry. The MDS indicated Resident 113 received skin and ulcer/injury treatments such as pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention, and pressure ulcer/injury care. A review of Resident 113's Assessment of Decubitus Ulcer Potential dated 9/29/2023, indicated a risk score of 23 or high risk. The higher the score, the greater is the potential to develop pressure ulcers. Residents with scores above (12) should be considered at risk. A review of Resident 1113's Wound Evaluation and Management Summary, dated 10/16/2023, indicated a recommendation from the wound doctor to off-load wound and reposition the resident per facility protocol on all the pressure injuries. A review of Resident 113's care plan for alteration in skin integrity related to presence of stage 4 on the sacrum (is the large, triangle-shaped bone at the base of the spine), stage 3 on the left medial thigh, and stage 2 (characterized by partial-thickness skin loss into but no deeper than the dermis [the middle layer of skin in the body]) on the left buttocks, initiated on 9/27/2023, indicated an intervention to turn and reposition the resident every 2 hours. A review of Resident 113's Adult Subacute Care 24-Hour Nursing Flow Sheet for 10/2023 indicated: On 10/16/2023, from 4 a.m. to 7 a.m., the resident was positioned on the left side. On 10/15/2023, from 7 p.m. to 11 p.m., there were no documented entries. On 10/16/2023, from 12 a.m. to 7 a.m. the resident was on her back. On 10/14/2023, from 7 a.m. to 11 p.m., there were no documented entries. On 12/15/2023, from 12 a.m. to 7 a.m. the resident was on her back. On 10/12/2023, from 11 a.m. to 7 a.m. of 10/13/2023, was left blank. 10/11/2023, from 4 p.m. to 9 p.m., the resident was on her right side, from 8 p.m. to 11 p.m., the resident was on her left side. 10/8/2023, from 10 p.m. to 1 a.m. of 10/9/2023, resident was on her right side. 10/6/2023, from 10 a.m. to 3 p.m., the resident was on semi-Fowler's position. 10/5/2023, From 10 p.m. to 1 a.m. of 10/6/2023, resident was on her left side. 10/3/2023, from 7 a.m. to 1 p.m., the resident was on her left side. 10/2/2023, from 12 p.m. to 3 p.m., the resident was on her back. During an interview on 10/18/2023, at 10:10 a.m., TN 2 stated Resident 113 should be turned and repositioned every two hours every 2 hours for the resident's welfare. During an interview and record review on 10/18/2023, at 12:26 p.m., reviewed Resident 113's Adult Subacute Care 24-Hour Nursing Flowsheet for 10/2023 with TN 1 and TN 2. TN 1 and TN 2 stated there were multiple documented entries that indicated Resident 113 was not turned and repositioned every 2 hours. TN 1 and TN 2 stated there is potential for development and/or worsening of pressure ulcers if the resident is not turned or repositioned every two hours. 2.b. A review of Resident 313's admission Record indicated the facility admitted Resident 313 on 5/23/2022 and readmitted the resident on 10/10/2023, with diagnoses including dependence on respirator, end stage renal disease, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of Resident 313's H&P, dated 10/14/2023, indicated Resident 313 did not have the capacity to understand and make decisions. A review of Resident 313's MDS, dated [DATE], indicated Resident 313 required total dependence on bed mobility, dressing, eating, toilet use, and personal hygiene with one to two-persons assist. The MDS indicated the resident was incontinent of bowel. The MDS indicated the resident was at risk for developing pressure ulcer/injuries and was receiving skin and ulcer/injury treatment such as pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention, and surgical wound care. A review of Resident 313's Assessment of Decubitus Ulcer Potential dated 10/16/2023, indicated a risk score of 25 or high risk. The higher the score, the greater is the potential to develop pressure ulcers. Residents with scores above (12) should be considered at risk. A review of Resident 313's Physician Orders, dated 10/10/2023, indicated an order to check low air loss mattress pressure every shift per resident's weight for skin management. A review of Resident 313's Care Plan, dated 10/18/2023, indicated the resident had alteration in skin integrity related to presence of right buttock unstageable pressure injury (the extent of tissue damage within the ulcer cannot be ascertained). The intervention included to turn and reposition the resident every two hours and to provide pressure relieving devices as indicated. During an observation and interview on 10/16/2023, at 9:46 a.m., with Licensed Vocational Nurse 8 (LVN 8), observed Resident 313's LALM inflated at maximum. LVN 8 stated the LALM should not be on maximum inflation when staff are not performing nursing care to the resident. LVN 8 stated the LALM should be set to alternating pressure and according to the resident's weight which is 200 lbs. LVN 8 stated not having the correct setting for the LALM had the potential for the resident to develop or cause worsening of pressure injuries. A review of Resident 313's Adult Subacute Care 24-Hour Nursing Flowsheet for 10/2023 indicated: On 10/16/2023, from 12 a.m. to 7 a.m. of 10/17/2023, resident was on her back. On 10/15/2023, from 10 a.m. to 1 p.m., the resident was on her back. On 10/13/2023, from 7 a.m. to 11 p.m., there were no documented entries. On 10/14/2023, from 12 a.m. to 7 a.m. the resident was on her back. During an interview and record review on 10/18/2023, at 10:10 a.m., reviewed Resident 313's Adult Subacute Care 24-Hour Nursing Flowsheet for 10/2023 with TN 1 and TN 2. TN 1 and TN 2 stated there were multiple documented entries that indicated Resident 313 was not turned and repositioned every 2 hours. TN 1 and TN 2 stated the LALM should not be set at max inflate and the resident should have been turned every 2 hours to prevent development or worsening of a pressure injury. During an interview on 10/20/2023, at 8:40 a.m., the Director of Staff Development (DSD) stated the LALM should always be turned on to maximize its therapeutic benefits. The DSD stated when the LALM was off it could have caused pressure injury. The DSD stated the staff should have turned the residents every two hours per policy to prevent skin breakdown. The DSD stated the LALM setting is based on the resident's weight. During an interview on 10/20/2023, at 9:36 a.m., the Director of Nursing (DON) stated the nursing staff should make sure residents were repositioned every two hours to prevent skin breakdown. The DON stated the LALM's power should be on to maximize its therapeutic benefits. The DON stated nursing staff should check the correct settings of the LALM during rounds. The DON stated the LALM should have the correct settings to prevent skin breakdown, discomfort and worsening of pressure injuries. A review of the facility's recent policy and procedure titled, Low Air Loss Mattress, last reviewed on 1/26/2023, indicated the purpose of this policy is to treat and prevent pressure ulcers, pressure relief, sheer reduction, moisture control, and friction reduction in residents of All Saints Healthcare. Low air loss mattresses will be used for residents who have actual or potential for pressure ulcers. A review of the facility's recent policy and procedure titled, Pressure Sore Prevention and Management, last reviewed on 7/14/2023, indicated on early interventions: Emphasis on turning schedule by all supervisory staff. Interventions: Pressure relieving mattresses for Residents at high risk. Turn q 2 hours while in bed. A review of the facility's recent policy and procedure titled, Decubitus Ulcer Staging, Documentation, Prevention, last reviewed on 1/26/2023, indicated Stage 3 and 4: Skin break with deep tissue involvement. 1. Notify doctor-obtain orders- Involve wound doctor in rounds and care plan orders. 2. Turn every two hours and reposition, use low air loss mattress. 3. Follow Stage 2 recommendations. 4. Document on Decubitus Form. Preventive Measures: 1. Bed Residents/Patients will be repositioned every two hours and PRN. There will be charting substantiating the repositioning and direction of the body turn. A review of the manufacturer's In-service and Operators guide for Medline Supra Low Air Loss and Alternating Pressure Mattress, undated, indicated for optimal pressure relief it is recommended that the system be set to alternate as much as possible. Insert white fittings on end of air tubes from overlay into fittings on control box- there is only one way they will click together. Turn on power switch on the control box- green light will indicate unit is on. A review of the manufacturer's Operating Instructions for K-6 & K-Z Elite & OEM Series, undated, indicated on operating instructions to press power key, the (amber) Standby LED will turn off and the (green) LED turns on. The control unit will turn on. 4.c. A review of Resident 45's Record of admission indicated Resident 45 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and personal history of traumatic brain injury. A review of Resident 45's Minimum Data Set (MDS - an assessment and care screening tool), dated 8/7/2023, indicated Resident 45 was rarely or never understood, totally dependent on one-to-two person physical assist for bed mobility, dressing, toilet use, and personal hygiene, had a history of stage three pressure ulcer (full thickness tissue loss where subcutaneous fat may be visible but bone, tendon or muscle is not exposed). The MDS indicated the resident had a pressure reducing device for his bed. A review of Resident 45's Physician's Orders, dated 10/3/2023, indicated an order to check low air loss mattress (LALM, a pressure reducing device) every shift and set at 180 per Resident 45's weight for skin management. A review of Resident 45's Resident Care Plan, dated 9/13/2023, indicated Resident 45's concerns and problems include alteration in skin integrity related to the presence of a posterior neck stage three pressure ulcer. Resident 45's care plan further indicated the approach plan included providing pressure relieving devices as indicated. During an observation, on 10/16/2023, at 9:14 a.m., inside Resident 45's room, Resident 45 was observed lying down in bed. At the foot of Resident 45's bed, the controls for Resident 45's low air loss mattress were observed with settings above 160 lbs., normal pressure, and static. During an interview with the Director of Staff Development (DSD), on 10/20/2023, at 8:57 a.m., the DSD stated the low air loss mattress settings are based on the resident's weight. The DSD stated the low air loss mattress settings should be set to alternating, not static. The DSD further stated if the settings on the low air loss mattress are not correct, it defeats the purpose of preventing skin breakdown. During an interview with the Director of Nursing (DON), on 10/20/2023, at 12:05 p.m., the DON stated the resident's low air loss mattress settings should be matched to the resident's weight. The DON stated there is a physician order to follow for low air loss mattress settings. The DON further stated it was not appropriate to set the low air loss mattress to max and/or static because it would increase the pressure, make the mattress firm, and can create skin problems. 4.d. A review of Resident 72's Record of admission indicated Resident 72 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including respiratory failure and anoxic brain damage (injuries caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). A review of Resident 72's MDS, dated [DATE], indicated Resident 72 was rarely or never understood, totally dependent with one-to-two person assist for bed mobility, dressing, toilet use, and personal hygiene, was at risk for developing pressure ulcers, and was using a pressure reducing device for his bed. A review of Resident 72's Physician's Orders, dated 10/16/2023, indicated an order to check Resident 72's low air loss mattress pressure every shift and set at 130 per Resident 72's weight for skin management. A review of Resident 72's Resident Care Plan, dated 10/10/2023, indicated Resident 72's concerns and problems include potential for pressure ulcer development related to bed mobility problem, bladder and bowel incontinence, and presence of trach (also known as a tracheostomy, an opening surgically created through the neck into the windpipe to allow air to fill the lungs) and gastrostomy tube (GT - a tube inserted through the belly that brings nutrition directly to the stomach). Resident 72's care plan further indicated the approach plan included low air loss mattress as ordered. During an observation, on 10/16/2023, at 8:51 a.m., inside Resident 72's room, Resident 72 was observed lying down in bed. At the foot of Resident 72's bed, the control for the low air loss mattress were observed with settings of 400 lbs. max, normal pressure, and static. During an interview with the Director of Staff Development (DSD), on 10/20/2023, at 8:57 a.m., the DSD stated the low air loss mattress settings are based on the resident's weight. The DSD stated the low air loss mattress settings should be set to alternating, not static. The DSD further stated if the settings on the low air loss mattress are not correct, it defeats the purpose of preventing skin breakdown. During an interview with the Director of Nursing (DON), on 10/20/2023, at 12:05 p.m., the DON stated resident's low air loss mattress settings should be matched to the resident's weight. The DON stated there is a physician order to follow for low air loss mattress settings. The DON further stated it is not appropriate to set the low air loss mattress to max and/or static because it would increase the pressure, make the mattress firm, and can create skin problems. A review of the facility's policy and procedure (P&P) titled, Decubitus Ulcer (Staging, Documentation, Prevention), reviewed 1/26/2023, indicated preventative measures include as necessary treatment orders will be obtained from the attending physician for mattress, air mattress, gel mattress, etc. A review of the facility's P&P titled, Low Air Loss Mattress, reviewed 1/26/2023, indicated low air loss mattresses will be used for residents who have actual or potential pressure ulcers and a physician's order will be obtained for the use of a low air loss mattress. 3. A review of Resident 18's Record of admission indicated the facility admitted the resident on 1/7/2022 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on respirator (ventilator, a device for maintaining artificial respiration), and pressure ulcer of other site, unspecified stage. A review of Resident 18's H&P, dated 9/28/2023, indicated the resident does not have assay to understand and make a decision due to encephalopathy (damage or disease that affects the brain). A review of Resident 18's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated the resident required total dependence (full staff performance every time) with bed mobility, dressing, eating, toilet use, and personal hygiene with physical assist from staff. The MDS indicated the feeding tube was performed while a resident of the facility. A review of Resident 18's Care Plan titled, Alteration in Skin Integrity, last evaluated date 9/30/2023, indicated a goal of decreasing in diameter by 0.1 centimeter (cm, a unit of measure) per week, with interventions including administer treatment as ordered. A review of Resident 18's Physician Orders indicated the following orders, dated 9/22/2023: - Renew treatment stage 4 of right lateral (side) ankle. Cleanse with normal saline (NS, sterile water) moist gauze, pat dry, apply betadine soaked 4x4 to wound bed, cover with dry gauze and foam dressing every day. - Stage 4 pressure wound of left distal plantar foot. Cleanse with NS, pat dry, apply betadine soaked 4x4 to wound bed, cover with dry gauze and foam dressing once per day. - Stage 4 of [NAME] (area facing upwards while standing) lateral foot: Cleanse with NS, moist gauze, pat dry, apply betadine-soaked gauze 4x4 to wound bed, cover with dry dressing and foam dressing every day. During a concurrent interview and record review on 10/20/2023 at 4:17 p.m. with the DON, Resident 18's Treatment Record for the month of 10/2023 was reviewed. The DON stated the treatment nurses sign the treatment record after the treatment has been performed. The DON stated if it is not documented, it was not sign. During a concurrent interview and record review on 10/20/2023 at 5:47 p.m., with Treatment Nurse 2 (TN 2), Resident 18's Treatment Record for the month of 10/2023, was reviewed. TN 2 stated she worked on 10/9/2023 but was off from 10/5/2023 to 10/8/2023. TN 2 stated the charge nurses should sign the treatment after they provide the treatment. TN 2 stated she provided the wound treatment on 10/9/2023 but did not sign the treatment record. TN 2 stated the following treatments were not signed off as done on the following dates: - Stage 4 pressure ulcer of right heel re-opened, for 6 days, on 10/5/2023, 10/6/2023, 10/7/2023, 10/8/2023, 10/9/2023, 10/15/2023. - Stage 4 of dorsolateral foot, for 2 days, on 10/11/2023 and 10/16/2023. - Stage 4 pressure ulcer of right lateral ankle, for one day, on 10/16/2023. - Stage 4 pressure wound of left distal plantar foot, on 10/16/2023. A review of the facility's policy and procedure titled, Decubitus Ulcer Staging, Documentation, Prevention, last reviewed and approved on 1/26/2023, indicated Stage 3 and 4: Skin break with deep tissue involvement. 1. Notify doctor-obtain orders- Involve wound doctor in rounds and care plan orders. Preventive Measures: 6. Proper documentation of the treatment performed via the Physician Orders will be in the treatment book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who has an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections (UTI, common infections that happen when bacteria, often from the skin or rectum, enter the urethra [duct that transmits urine from the bladder to the exterior of the body during urination], and infect the urinary tract) to the extent possible for four of 52 sampled residents (Residents 16, 31, 94, and 20) by: 1. Failing to apply a leg strap (a device to secure the catheter to prevent tugging and pulling) to secure the urinary catheter (a procedure used to drain the bladder and collect urine, through a flexible tube called a catheter) of Resident 16. 2. Failing to ensure Resident 31 and Resident 94's drainage bags were attached to the side where the leg strap was placed. 3. Failing to ensure Resident 20's urinary catheter tubing was free from coils or loops. These deficient practices had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it is can be excreted]) due to tugging and pulling of the urinary catheter causing trauma to the urinary meatus (where urine leaves the body through a hole at the end of the urethra) and for urine to backflow in the urinary catheter tubing. Findings: a. A review of Resident 16's admission Record indicated the facility admitted the resident on 5/10/2019, with diagnoses including retention of urine (a condition in which a person is unable to empty all the urine from your bladder), hypo-osmolality (the most common disorder of fluid and electrolyte balance) and hyponatremia (the sodium level in the blood is below normal), and spastic quadriplegic cerebral palsy (characterized by paralysis of both arms and both legs, with muscle stiffness). A review of Resident 16's History and Physical (H&P), dated 5/6/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/27/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was totally dependent on staff with bed mobility, dressing, eating, toilet use, and personal hygiene with one to two-persons assist. A review of Resident 16's Physician Orders, dated 5/28/2023, indicated an order for Foley catheter (a common type of indwelling catheter) Fr #16X10 (an indwelling catheter size): Change every (q) month and if necessary (prn), out or plugged (urinary retention). A review of Resident 16's Care Plan, last evaluated on 8/2023, indicated the resident was at risk for UTI related to long term use of Foley catheter. During a concurrent observation and interview on 10/16/2023, at 9:58 a.m., with Licensed Vocational Nurse 5 (LVN 5), observed Resident 16's urinary catheter without a leg strap. LVN 5 stated there the urinary catheter should be secured with a leg strap to prevent infection and trauma to the urinary meatus (opening of the urethra) During an interview on 10/20/2023, at 8:40 a.m., with the Director of Staff Development (DSD), the DSD stated nursing staff should have secured Resident 16's urinary catheter by using a leg strap. The DSD stated using a leg strap or a securement device prevents dislodgement, pulling and tugging of the urinary catheter, that could cause a tear on the urinary meatus creating a portal for entry for bacteria. During an interview on 10/20/2023, at 9:36 a.m., with the Director of Nursing (DON), the DON stated the nursing staff should have applied a leg strap to Resident 16's urinary catheter to keep it in place. The pulling and tugging of the urinary catheter could cause trauma or skin tear to the resident's urinary meatus creating a portal for entry for bacteria. A review of the facility's recent policy and procedure titled, Catheter Care and Urinary Bag Privacy Cover, last reviewed on 1/26/2023, indicated check position of drainage bag: a. Below level of catheter and bladder. b. Secure tubing to patient thigh with Catheter Posey or Fabric leg strap. c. Attach to bed frame. d. Cover catheter bag with Privacy Cover to assure patient privacy. A review of the facility's recent policy and procedure titled, Catheter Associated Urinary Tract Infection, last reviewed on 10/12/2019, indicated catheter care and evaluation of indwelling catheters will be used along with best practices to prevent Catheter Associated Urinary Tract Infection. Maintenance to Prevent CAUTI: 2. Ensure the catheter is properly secured to the resident. b. A review of Resident 31's Record of admission indicated the facility admitted the resident on 8/10/2010 and readmitted the resident on 5/21/2022 with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 31's History and Physical dated 9/28/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 31's MDS, dated [DATE], indicated the resident had persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of resident 31's care plan on risk for UTI related to the of use urinary catheter for urinary retention updated on 5/2023 and last reviewed 8/2023 indicated at risk for complications such as pain, injury, and infection. c. A review of Resident 94's Record of admission indicated the facility admitted the resident on 3/20/2023 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 94's History and Physical dated 6/28/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 94's MDS, dated [DATE], indicated the resident had persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 94's care plan on risk for UTI related to the use of urinary catheter for wound management initiated on 6/29/2023 and last reviewed 9/2023 indicated at risk for complications such as dislodgement, bleeding, pain, injury, and infection. During an observation on 10/16/2023 at 1:44 p.m., observed Resident 31's and 94's urinary drainage bags attached to the right side of the bed. During a concurrent observation and interview on 10/16/2023 at 1:55 p.m., with Certified Nursing Assistant 2 (CNA 2), observed Resident 31's and 94's urinary drainage bag attached to the right side of the bed and their leg strap applied on the residents' left leg. CNA 2 stated the urinary drainage bag should be placed on the left side of the residents' bed to prevent pulling, bleeding, pain, injury, and infection. During an interview on 10/16/2023 at 2:02 p.m., with LVN 6, LVN 6 stated Resident 31's and 94's leg straps were on the residents' left leg. LVN 6 stated CNA 2 should have placed the urinary drainage bags to the left side of the bed after providing the residents ADL care to prevent pulling on the urinary catheter, which may lead to bleeding, pain, injury, and infection. During an interview on 10/17/2023 at 2:00 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated nursing staff should ensure proper placement of the drainage bag to prevent pulling on the catheter prior to leaving the room. The MDSC stated Resident 31 and 94's urinary drainage bag should have been attached to the right side of the bed to prevent pulling which may lead to bleeding, pain, injury, and infection. A review of the facility's policy and procedure titled, Catheter Care and Urinary Bag Privacy Cover, last reviewed 1/26/2023, indicated a purpose to ensure decrease in the risk of a UTI. The policy indicated do not pull on the catheter and check the position of the catheter, tubing, and drainage bag. d. A review of Resident 20's Record of admission indicated the facility admitted Resident 20 on 12/6/2007 and readmitted the resident on 12/24/2022 with diagnoses including chronic respiratory failure and anoxic brain damage (injuries caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). A review of Resident 20's MDS, dated [DATE], indicated Resident 20 was rarely or never understood and had an indwelling catheter. A review of Resident 20's Resident Care Plan, dated 12/27/2023, indicated Resident 20's concerns and problems include at risk for UTI related to use of urinary catheter for urinary retention. Resident 20's care plan further indicated the approach plan included keeping the urinary catheter tubing free from coils and keeping the bag below the waist. During a concurrent observation and interview with LVN 16, on 10/16/2023, at 12:08 p.m., inside Resident 20's room, LVN 16 stated Resident 20's urinary catheter was coiled. Resident 16's urinary catheter was observed with cloudy, light-yellow liquid in the tubing. LVN 16 stated the certified nursing assistants could have recently changed the resident and did not place the urinary catheter in the right place. LVN 16 stated if there are coils in the urinary catheter tubing, the urine would not be able to flow freely and cause the urine to back up. LVN 16 stated if the urine backs up, it could possibly cause a UTI for Resident 20. During an interview with LVN 17, on 10/16/2023, at 12:13 p.m., LVN 17 stated there should not be any coils on a urinary catheter tubing to allow urine to flow freely and prevent backups. LVN 17 further stated urinary backup can cause UTIs. During an interview with the DSD, on 10/20/2023, at 8:57 a.m., the DSD stated loops or coils in the urinary catheter are not appropriate because it will not allow urine to drain properly. The DSD further stated if a urinary catheter is not allowed to drain properly, it can possibly cause an infection. During an interview with the DON, on 10/20/2023, at 12:05 p.m., the DON stated the urinary catheter drainage bag (container that collects urine from a urinary catheter) should be placed below the resident's bladder and at the foot of the bed. The DON stated there should not be any loops or coils on the urinary catheter tubing. The DON stated the urinary catheter tubing should be straight to avoid clogging. The DON further stated loops or coils in the urinary catheter tubing can cause urinary retention and increase the chances for a UTI. A review of the facility's policy and procedure (P&P) titled, Catheter Associated Urinary Tract Infection (CAUTI), reviewed 1/26/2023, indicated catheter care and evaluation of indwelling catheters will be used along with best practices to prevent catheter associated urinary tract infections. The P&P indicated CAUTI prevention practices include maintaining closed drainage system and unobstructed urine flow. The P&P further indicated maintenance to prevent CAUTI includes ensuring that the catheter lines are not kinked, and urine flow is unobstructed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 35's Record of admission indicated the facility admitted the resident on 12/21/2011 and readmitted her on 10/20/2020 with diagnoses including spastic diplegic cerebral palsy (CP - a condition that is caused by abnormal brain development that affects a person's ability to control their muscles, mainly in the legs), epilepsy (brain disorder that caused recurring seizures), and neuromuscular dysfunction of bladder (person lacks bladder control due to brain or nerve problems). A review of Resident 35's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff for dressing, feeding, personal hygiene, and all other ADLs. During a concurrent observation and interview on 10/16/2023 at 9:31 a.m., LVN 13 verified that Resident 35's GT line did not have a label with the date when it was last changed. LVN 13 stated that it is important to have the dates when it was changed on the GT line to prevent infection. During an interview on 10/19/23 at 10:13a.m., Registered Nurse 8 (RN 8) stated that missing dates on the GT line and irrigation bottle had the potential for infection. During an interview on 10/20/2023 at 9:09 a.m., the Director of Staff Development (DSD) stated that it is important to have the date when the GT line and irrigation bottle were last changed because the missing date had the potential to result in introducing infection to the resident. During an interview on 10/5/2023 at 3:08 p.m., the Director of Nursing (DON) stated that if the dates on the GT line and irrigation bottle are missing then there is no way to know how long the tubing has been connected to the resident and when it is due to be changed, which creates the potential for cross contamination and infection. A review of the facility's policy and procedure titled, GT Extension Set Use and storage, last reviewed 1/26/2023, indicated the following: GT extension set will be labeled with date of when it was changed. A review of the facility's policy and procedure titled, Irrigation bottle, last reviewed 1/26/2023, indicated: Irrigation bottles will be labeled with patient's last name, date, and room/bed#. Based on observation, interview, and record review, the facility failed to ensure four of 15 sampled residents (Residents 13, 1, 35, and 109) receiving enteral nutrition (also known as tube feeding is a way of delivering nutrition directly to your stomach or small intestine) were provided care and services as assessed and ordered by the residents' physicians by failing to: 1. Ensure Resident 13's tube feeding formula, in use, had a legible time written on the label when it was hung. Also, another tube feeding formula, which was not in use, was hung in advance with no label indicating date and time. 2. Ensure Resident 1's tube feeding formula had a label indicating the time it was hung. 3. Ensure Resident 109 and Resident 35's feeding tubings had labels indicating the dates and times they were changed. 4. Ensure Resident 109's irrigation syringe had a label indicating the date and time it was changed. These deficient practices had the potential to result in increased risks for gastrointestinal problems. Findings: a. A review of Resident 13's Record of admission indicated the facility readmitted the resident on 9/18/2023 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), encounter for attention to gastrostomy, and gastro-esophageal reflux disease (GERD, a condition in which the stomach contents leak backward from the stomach into the esophagus). A review of Resident 13's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 9/1/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 13 required total dependence (full staff performance every time) with bed mobility, dressing, and eating with physical assist from staff. The MDS indicated Resident 13 had a feeding tube. A review of Resident 13's History and Physical, dated 9/18/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 13's Physician Orders, dated 9/18/2023, indicated gastrostomy tube (GT - a tube inserted through the belly that brings nutrition directly to the stomach) feeding: Fibersource HN (a nutritionally complete tube feeding formula with fiber) at 45 cc/hour (hr) x 22 hours via pump to provide 990 cc/1188 kilocalories (kcals, a unit of measure) x22 hrs/day average. During a concurrent observation and interview on 10/16/2023 at 10:28 a.m., at Resident 13's bed side, the Director of Staff Development (DSD) stated the GT formula dated 10/15/2023 and the time on the label could not be read. The DSD stated the formula was good for a certain period, from the time it was spiked/punctured. The DSD stated she did not know what time it was hung. The DSD stated she would discard this and ask the assigned charge nurse to replace it. Observed another tube feeding formula hanging on the same tube-feeding pole. The DSD stated the second tube feeding formula bag hung with no label of resident's name, date, and time of when it was hung. The DSD stated she would also discard this. The DSD stated licensed nurses had been in-serviced (provided training) to only spike it when it is ready to be administered because the time indicates when the tube feeding formula was hung. During an interview on 10/20/2023 at 4:18 p.m., the DON stated charge nurses were responsible in changing the tube feeding formula. The DON stated the label indicates the date and time of when it was hung. The DON stated the accuracy of when it was hung shows how long the milk/formula is good for. The DON stated the licensed nurses are not supposed to spike and hung the tube feeding formula and leave it there. The DON stated the facility's practice is to label with date and time and hung as soon as they are ready to administer it. A review of the facility's policy and procedure (P&P) titled, Enteral Feeding - General Policy, last reviewed and approved on 1/26/2023, indicated enteral nutrition is provided for those residents who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. The P&P indicated the storage of formula to be labeled with time, date, resident's name and nurse's initials when hung. b. A review of Resident 1's Record of admission indicated the facility readmitted the resident on 2/26/2018 with diagnoses including chronic respiratory failure, encounter for attention to gastrostomy, and GERD. A review of Resident 1's History and Physical, dated 2/11/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 1's Physician Orders, dated 6/2/2023, indicated GT feeding: Promote with fiber at 60 cc/hr x22 hrs via pump to provide 1320 cc/1320 kcals every 24 hrs. A review of Resident 1's MDS, dated [DATE], indicated the resident required total dependence with bed mobility, dressing, and eating with physical assist from staff. The MDS indicated the feeding tube was performed while a resident of the facility. During an observation on 10/16/2023 at 11:56 a.m., Resident 1 was observed with a tube feeding formula dated 10/15/2023. Observed that the time the tube feeding was started was not indicated. During a concurrent observation and interview on 10/16/2023 at 12:26 p.m., at Resident 1's bed side, LVN 22 stated the resident has a tube feeding formula running without a label indicating the time the tube feeding was started. LVN 22 stated the time should be indicated on the label. Observed LVN checked tube feeding formula and tubing. LVN 22 stated she did not know what time the resident's tube feeding was hung. During an interview on 10/20/2023 at 4:18 p.m., the DON stated charge nurses are responsible in changing the tube feeding formula. The DON stated the label indicates the date and time of when it was hung. The DON stated the accuracy of when it was hung shows how long the milk/formula is good for. The DON stated the licensed nurses are not supposed to spike and hung the tube feeding formula and leave it there. The DON stated the facility's practice is to label with date and time and hung as soon as they are ready to administer it. A review of the facility's policy and procedure (P&P) titled, Enteral Feeding - General Policy, last reviewed and approved on 1/26/2023, indicated enteral nutrition is provided for those residents who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. The P&P indicated the storage of formula to be labeled with time, date, resident's name, and nurse's initials when hung. c. A review of Resident 109's Record of admission indicated the facility admitted the resident on 9/11/2023 with diagnoses including spastic diplegic cerebral palsy (CP - a condition that is caused by abnormal brain development that affects a person's ability to control their muscles, mainly in the legs ), epilepsy (brain disorder that causes recurring seizures), and neuromuscular dysfunction of the bladder (person lacks bladder control due to brain or nerve problems). A review of Resident 109's History and Physical, dated 9/14/2023, indicated that the resident was non-verbal and had severe neurological impairment. A review of Resident 109's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff for dressing, feeding, personal hygiene, and all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 10/16/2023 at 12:43 p.m., Resident 109 was observed in bed with tube feeding formula Peptamen 1.5 (formula for enteral feeding), dated 10/16/2023, running. During a concurrent interview, Licensed Vocational Nurse 11 (LVN 11) stated that Resident 109's GT line did not have a label with the date when it was last changed. Furthermore, observed irrigation bottle (bottle with syringe used for administration of medication through GT) did not have a label with the resident's name and the last date and time it was changed. LVN 11 stated that the feeding line and irrigation bottle should have the date when it was last changed. LVN 11 stated that she changed the irrigation bottle in the morning but forgot to put the date. LVN 11 stated that it is important to have the dates on the enteral feeding tubing and irrigation bottle to prevent infection. A review of the facility's policy and procedure titled GT Extension Set Use and storage, last reviewed 1/26/2023, indicated the following: GT extension set will be labeled with date of when it was changed. A review of the facility's policy and procedure titled, Irrigation bottle, last reviewed 1/26/2023, indicated: Irrigation bottles will be labeled with patient's last name, date, and room/bed#.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 61's admission Record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses including spastic quadriplegic cerebral palsy (CP - a condition that is caused by abnormal brain development that affects a person's ability to control their muscles ), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and convulsion (rapid, involutory muscle contractions that cause uncontrollable shaking and limb movement). A review of Resident 61's History and Physical, dated [DATE], indicated the resident was non-verbal. A review of Resident 109's Minimum Data Set (MDS - an assessment and care screening tool), dated [DATE], indicated that the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff for dressing, feeding, personal hygiene, and all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During concurrent observation and interview on [DATE] at 11:23 a.m. with Respiratory Therapist 7 (RT 7), observed Resident 61 on a ventilator with the sterile water bag connected to the aerosol system. RT 7 verified that there was no date on the sterile water bag of when it was last changed. During an interview on [DATE] at 8:51 a.m., with the Director of Respiratory Therapy (DRT), the DRT stated that the sterile water bags need to be labeled with the date and time they were changed per the facility policy. During an interview on [DATE] at 9:09 a.m., with the Director of Staff Development (DSD), the DSD stated that it is important to have the date when the sterile water bag was last changed because using expired water had the potential to result in introducing infection to the resident. During an interview on [DATE] at 3:08 p.m., with the Director of Nursing (DON), the DON stated that if the date on the water bag was missing then there is no way to know how long it has been connected to the resident and when it is due to be changed, which creates the potential for cross contamination and infection. A review of the facility's policy and procedure titled Use of sterile water for humidification, last reviewed [DATE], indicated the following: Sterile water bags will be dated and timed when they are changed. Based on observation, interview and record review the facility failed to ensure that a resident who receives respiratory care was provided such care consistent with professional standards of practice for four out of 11 sampled residents (Residents 95, 59, 55 and 61) by: 1. Failing to discard Residents 95, 59 and 55's sterile water bag used for the aerosol system (a system of liquid or solid particles uniformly distributed in a finely divided state through a gas, usually air) per facility policy. 2. Failing to label Resident 61's sterile water bag with the date for when it was last changed. These deficient practices had the potential to result in respiratory complications from using expired sterile water for moisturization of respiratory passages. Findings: 1. a. A review of Resident 95's admission Record indicated the facility admitted Resident 95 on [DATE] and the facility readmitted Resident 95 on [DATE], with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy, and gastrostomy (a surgical procedure used to insert a tube, often referred to as a g-tube, through the abdomen and into the stomach). A review of Resident 95's History and Physical (H&P), dated [DATE], indicated Resident 95 had the capacity to understand and make decisions. A review of Resident 95's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], indicated Resident 95 had the ability to make self-understood and understand others. The MDS indicated Resident 95 was receiving respiratory treatments such as oxygen therapy (a treatment that provides the body with supplemental, or extra oxygen), suctioning (the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place), tracheostomy care, and on invasive mechanical ventilator (a machine that takes over the work of breathing when a person is not able to breathe enough of their own). A review of Resident 95' Physician Orders, dated [DATE], indicated an order for: -May use heated humidifier (provide adequate temperature and humidity without affecting the respiratory pattern) to prevent mucus plugs (can partially or completely obstruct one or more airways and cause serious consequences). A review of Resident 95's care plan, last evaluated on 7/2023, indicated the resident with presence of tracheostomy with a potential for infection. During a concurrent observation and interview on [DATE], at 10:50 a.m., with Licensed Vocational Nurse 5 (LVN 5), observed Resident 95's sterile water bag for aerosol system dated [DATE]. LVN 5 stated the sterile water IV bag should have been discarded to prevent respiratory infection to the resident. 1. b. A review of Resident 59's admission Record indicated the facility admitted Resident 59 on [DATE] and the facility readmitted Resident 59 on [DATE], with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. A review of Resident 59's MDS, dated [DATE], indicated Resident 59 rarely to never had the ability to make self-understood and sometimes understands others. The MDS indicated Resident 95 was receiving respiratory treatments such as oxygen therapy, suctioning, tracheostomy care, and on invasive mechanical ventilator. A review of Resident 59's Physician Orders, dated [DATE], indicated an order to change aerosol setup every (q) Thursday and if necessary (PRN). A review of Resident 59's Care Plan, last reviewed on 8/2023, indicated the resident with presence of tracheostomy with a potential for infection. During a concurrent observation and interview on [DATE], at 12:04 p.m., with Respiratory Therapist 4 (RT 4), observed Resident 59's sterile water IV bag for aerosol system dated [DATE], at 2:30 a.m. RT 4 stated the sterile water bag should have been discarded and replaced since it was only good for 72 hours. 1. c. A review of Resident 55's admission Record indicated the facility admitted Resident 55 on [DATE] and readmitted the resident on [DATE], with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. A review of Resident 55's MDS, dated [DATE], indicated the resident had sometimes the ability to make self-understood and understand others. The MDS indicated the resident was receiving respiratory treatments such as oxygen therapy, suctioning, tracheostomy care, and on invasive mechanical ventilator. A review of Resident 55's Physician Orders, dated [DATE], indicated an order to change aerosol setup every Thursday and PRN. A review of Resident 55's care plan, last reviewed on 9/2023, indicated the resident with presence of tracheostomy with a potential for infection. During a concurrent observation and interview on [DATE], at 11:11 a.m., with Registered Nurse 6 (RN 6), observed Resident 55's sterile water bag for aerosol system dated [DATE]. RN 6 stated the bag was only good for 72 hours and should have been discarded for infection control. During a concurrent observation and interview on [DATE], at 11:38 a.m., with Respiratory Therapist 5 (RT 5), observed Resident 55's sterile water bag for aerosol system dated [DATE]. RT 5 stated the bag was only good for 72 hours and should have been discarded for infection control. During an interview on [DATE], at 11:39 a.m., with the Director of Respiratory Therapy (DRT), the DRT stated the sterile water bags were only good for 3 days or 72 hours. The DRT stated the RTs should have removed and discarded the bags for infection control and prevention and per facility policy. During an interview on [DATE], at 9:36 a.m., the Director of Nursing (DON) stated the licensed staff should have monitored the sterile water bag for its expiration date. The sterile water is used for humidification of the air for residents with ventilator and using expired sterile water can cause infections. A review of the facility's recent policy and procedure titled, Use of Sterile Water Humidification, last reviewed on [DATE], indicated sterile water bags to humidify ventilator dependent residents will be changed every seventy-two (72) hours as needed (PRN). Sterile water bags will be dated and timed when they are changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b.3. A review of Resident 109's admission Record indicated that the facility admitted the resident on 9/11/2023 with diagnoses including spastic diplegic cerebral palsy (CP - a condition that is caused by abnormal brain development that affects a person's ability to control their muscles, mainly in the legs), epilepsy (brain disorder that causes recurring seizures), and neuromuscular dysfunction of the bladder (person lacks bladder control due to brain or nerve problems). A review of Resident 109's History and Physical dated 9/14/2023, indicated that the resident was non-verbal and had severe neurological impairment. A review of Resident 109's MDS, dated [DATE], indicated that the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff for dressing, feeding, personal hygiene, and all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a concurrent observation and interview on 10/18/2023 at 9:17 a.m. with Registered Nurse 9 (RN 9), observed Resident 109 in the bed with all four side rails up. RN stated according to physician order the resident had an order for all four side rails to be up. A review of Resident 109's Physician Order dated 9/11/2023 indicated that side rails should be up for safety (informed consent verified with Medical Doctor.) During a concurrent interview and record review on 10/18/2023 at 10:13 a.m., with Registered Nurse 8 (RN 8), Resident 109's physical chart was reviewed. RN 8 stated there was no documented evidence of a signed consent for the use of the side rails. During an interview on 10/20/2023 at 9:19 a.m., the Director of Staff Development (DSD) stated that side rails are considered a form of restraint and there should have been a consent for its use. The DSD stated the residents have the right to refuse the use of side rails. During an interview on 10/20/2023 at 3:08 p.m., with the Director of Nursing (DON), the DON stated a consent for using side rails was necessary, and that it was a violation of the resident's rights if the side rails were used without consent. A review of the facility's policy and procedure titled Informed Consent, last reviewed 1/26/2023, indicated the following: Restraints and psychotropic medication consents must be obtained by the ordering physician prior to administration of those orders. Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (also referred to as 'bed rails' and 'bed side rails', are adjustable metal or rigid plastic bars that attach to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for four of four sampled residents (Residents 10, 1, 74 and 109) by: 1. Failing to clarify with the physician the number of side rails ordered to be used for Resident 10. 2. Failing to obtain informed consent from the resident or resident representative for the use of full siderails prior to use for Resident 74, 1, and 109. These deficient practices had the potential to result in psychosocial harm, physical harm from entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) and death of residents. Findings: 1a. A review of Resident 10's Record of admission indicated the facility admitted the resident on 5/6/2005 and readmitted the resident on 6/25/2020 with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness) and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). A review of Resident 10's History and Physical dated 6/2/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 10's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/13/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 10's Physician Orders dated 6/1/2023, indicated an order for side rails up due to seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain that cause changes in behavior, movements, feelings, and levels of consciousness). A review of Resident 10's informed consent for general medical care indicated a treatment order for side rails up due to seizure disorder, signed by the resident's representative on 6/29/2020. A review of Resident 10's Bedrail Use and Entrapment Risk Evaluation form dated 11/15/2022, indicated bilateral bedrails to prevent falls and injuries. A review of Resident 10's care plan on potential for injury initiated on 11/15/2022 and last reviewed on 8/2023, indicated the use of two siderails when in bed or crib for safety and prevention of falls or injuries related to impaired cognition, seizure disorder, and muscle spasticity. During an observation on 10/16/2023 at 11:15 a.m., observed Resident 10 in her room, lying in bed with all four side rails up. During an interview on 10/18/2023 at 8:09 a.m., with Registered Nurse 3 (RN 3), RN 3 stated Resident 10 had an order for all side rails up due to seizure disorder and for safety except when ADL care is being provided. During a concurrent interview and record review on 10/18/2023 at 11:08 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 10's bedrail use and entrapment risk evaluation was reviewed. The evaluation indicated to have the resident's bilateral side rails up. The MDSC stated the physician's order and informed consent indicated side rails up. The MDSC stated the informed consent and physician's order should have been clarified with the physician to ensure a least restrictive device is in place. A review of the facility's policy and procedure titled, Informed Consent, last reviewed on 1/26/2023, indicated a purpose to establish that a resident or responsible party understands and accepts treatment ordered by the physician. The policy indicated consents must be obtained by the ordering physician prior to administration of the orders. b.1. A review of Resident 74's Record of admission indicated the facility admitted the resident on 11/12/2020, with diagnoses including chronic respiratory failure, dependence on respirator, tracheostomy, gastrostomy, and anoxic brain damage (a condition that occurs when the oxygen supply to the brain was completely cut off). A review of Resident 74's History and Physical dated 12/6/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 10's MDS, dated [DATE], indicated the resident had persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 74's Physician Orders dated 11/12/2020, indicated an order for side rails up due to seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain that cause changes in behavior, movements, feelings, and levels of consciousness). A review of Resident 74's informed consent for general medical care indicated a treatment order for two (2) side rails up. The reason indicated for the treatment was seizure disorder. The informed undated consent was signed by the resident's representative. A review of Resident 74's Bedrail Use and Entrapment Risk Evaluation form with a date of 11/18/2022, indicated full rails for safety. During a concurrent observation and interview on 10/16/2023 at 11:42 a.m., with Licensed Vocational Nurse 9 (LVN 9), observed Resident 74's right foot with a heel protector positioned in between the right upper and lower quarter rails. LVN 9 stated the resident needed to be repositioned for safety. LVN 9 stated the resident had always been using full siderails up except during ADL care and turning and repositioning due to seizure disorder. During a concurrent interview and record review on 10/16/2023 at 2:45 p.m., with Registered Nurse 2 (RN 2), Resident 74's physician order and bedrail use and entrapment risk evaluation, and informed consent were reviewed. RN 2 stated the physician order and bedrail use and entrapment risk evaluation indicated to have all siderails up. RN 2 stated the informed consent signed by the resident's representative indicated to use two side rails. RN 2 stated the physician's order should be clarified with the physician and the entrapment risk evaluation should have been updated. During a concurrent interview and record review on 10/20/2023 at 9:52 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 74's physician order and bedrail use and entrapment risk evaluation, and informed consent were reviewed. The MDSC stated the undated informed consent indicated consent obtained for use of two siderails up. The MDSC stated the physician's order and bedrail use and entrapment risk evaluation indicated to use all siderails up. The MDSC stated the physician's order should have been clarified with the physician and the entrapment risk evaluation should have been reviewed. The MDSC stated the presence of all siderails up placed Resident 74 at risk for harm and injury due to entrapment. A review of the facility's policy and procedure titled, Informed Consent, last reviewed on 1/26/2023, indicated a purpose to establish that a resident or responsible party understands and accepts treatment ordered by the physician. The policy indicated consents must be obtained by the ordering physician prior to administration of the orders. 2. a. A review of Resident 1's Record of admission indicated the facility readmitted the resident on 2/26/2018 with diagnoses including chronic respiratory failure, encounter for attention to gastrostomy, and gastro-esophageal reflux disease (GERD, a condition in which the stomach contents leak backward from the stomach into the esophagus). A review of Resident 1's History and Physical, dated 2/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's MDS, dated [DATE], indicated the resident requires total dependence with bed mobility, dressing, and eating with physical assist from staff. A review of Resident 1's Physician Orders, dated 2/26/2018, indicated an order for side rails up due to non-restraint due to ADLs and mobility. During an observation on 10/16/2023 at 2:23 p.m., observed Resident 1 lying in bed, with bilateral side rails up x4. During a concurrent observation and interview on 10/17/2023 at 11:37 a.m., with Certified Nursing Assistant 6 (CNA 6), observed Resident 1 lying in bed, with all side rails up. CNA 6 stated Resident 1's all four side rails are up all the time. During a concurrent interview and record review of Resident 1's bed rail assessment, care plans and informed consents, on 10/17/2023 at 4:50 p.m., the MDSC stated the following: - Bed rail assessment, dated 2/20/23, full rails. Reassessed side rails annually, last eval 8/4/2023, side rails up for safety d/t poor balance, visual check 1-2 hours. MDSC stated no changes in the number of side rails. - Informed consent side rails up, no sign who took the consent, no MD signature, and no date. - Care plan titled potential for falls/ injuries, dated 2/20/2023, place side rails up x2 when in bed, 8/2023. - Care plan titled, Potential for seizure activity, place side rails x2 when in bed, re-eval 8/2023. The MDSC stated Resident 1's side rails should have indicated x4 in the informed consent and care plans. The MDSC stated because the bed rail assessment done by the interdisciplinary team (IDT, a conduct the person-centered services planning and participates in ongoing care management activities) indicated full side rails which is x4. During an interview on 10/20/2023 at 3:57 p.m., the Director of Nursing (DON) stated the charge nurses obtains the admission packets and whoever is doing the admission packet completing the side rails. The DON stated informed consents to obtain side rails for patient safety and family should know that side rails use as part of the consent. During a concurrent interview and record review on 10/20/2023 at 4:01 p.m., with the DON, Resident 1's informed consent for side rails was reviewed. The DON stated the informed consent was not signed. The DON stated it should have been signed by the resident's representative when the consent was obtained by either from the physician or the RN who obtained the informed consent on behalf of the physician. A review of the facility's policy and procedure titled, Informed Consent, last reviewed on 1/26/2023, indicated a purpose to establish that a resident or responsible party understands and accepts treatment ordered by the physician. The policy indicated consents must be obtained by the ordering physician prior to administration of the orders.

Based on interview and record review, the facility failed to ensure that licensed nursing staff have the specific competency (measurable pattern of knowledge, abilities, behaviors in order to perform occupational functions successfully) and skills set necessary to care for residents' needs for five out of five licensed nursing staff (Registered Nurse 1 [RN 1], Licensed Vocational Nurse 1/[LVN 1], LVN 2, LVN 3, and LVN 5 investigated under the Sufficient and Competent Nurse Staffing task. This deficient practice placed all residents care for by RN 1 and LVNs 1, 2, 3, and 5) at risk of not receiving care to meet their needs. Findings: A review of the facility's undated Job Description for RN and LVN Adult and Pediatric Units indicated the duties and responsibilities included, but not limited to the following: 1.Prepare, administer medications as ordered by the physician. 2. Check resident charts for specific treatment, medication orders, schedules, etc., daily. 3. Review Medication Administration Records (MAR) for completeness of information, accuracy in the transcription of physician orders and adherence to stop order policies on assigned patients. A review of the documents titled, RN and LVN Annual Skills List for LVN 3, dated 7/20/2023, and for LVN 5 dated 10/2/2023, did not specify the two LN were evaluated for their skills on the routes for medication administration. During an interview on 10/19/2023 at 9:21 a.m., the Director of Staff Development (DSD) stated all licensed nurses were provided a Competency Orientation Training Checklist on the first day of training to be completed throughout the duration of orientation. On 10/19/2023 at 9:31 a.m., an interview with the DSD and a concurrent review of the employee files for LVN 1, LVN 2, LVN 3, LVN 5, and RN 1 was conducted. The DSD stated part of the checklist was training on medication administration. The DSD stated and verified that the medication administration part did not specify the routes for medication administration. The DSD verified that Annual Skill list for LVN 3 and LVN 5 did not specify the routes of administration reviewed. The DSD stated there was no documented evidence in the checklist and annuals skills list of medication administration specific to the gastrostomy tube (GT - a surgical procedure to insert a tube through the belly into the stomach used for feeding and medication administration) route. The DSD stated other skills checked during orientation included GT types and care, feeding administration, etc. but not the routes of medication administration to include administration via GT. During an interview on 10/19/2023 at 11:15 p.m., the DSD stated performance evaluations were conducted by the Director of Nursing (DON) yearly from the employee hire date. The DSD stated the facility did not have actual skills check or skills fair to check the licensed nurses' competencies. During an interview on 10/20/2023 at 9 a.m., the DON stated she oversees the annual performance evaluations for all nursing staff based on their date of hire. The DON stated she discusses and provide performance feedback regarding the skills necessary to provide care to the residents. The DON stated there was no actual return demonstration of the skills set required during the performance evaluation. A review of the facility's policy and procedure titled, Employee Performance and Skills Evaluation, last reviewed on 1/26/2023, indicated a policy statement that annual performance and skills evaluations will be done for all clinical employees. The policy indicated the performance evaluation form will include job performance, job knowledge, safety, and quality of work to name a few. The policy indicated the performance evaluation will be used as a tool for employee development.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services to assure its medication administration was accurate, free from errors, followed physician's orders, and established policies and procedures (P&P) for three of five sample residents (Residents 22, 43, and 68) and three of five licensed Vocational Nurses (LVNs 1, 2, and 3) observed for medication pass. The facility failed to: 1a. Ensure LVN 1 read the medicine label and compare with the Medication Administration Record (MAR) to ensure Resident 22 received the correct dose of Potassium chloride (KCl, medicine used to prevent or treat low potassium levels in the body; potassium is a mineral the body needs for proper functioning of several organs including the heart) through Resident 22's gastrostomy tube (GT, a soft tube inserted during surgery into the stomach through the belly to deliver food and medications on a person unable to swallow), as ordered by the physician. 1b. Ensure LVN 1 clarified the order of Colace to give to Resident 22 through the GT and not attempt to place a capsule in hot water following standard of practice. 1c. Ensure LVN 1 did not mix three of eight medications for administration through Resident 22's GT, following the facility's P&P on Medication Pass to give medications one at a time. 2a. Failing to administer 50 milliliters (ml, a unit of measurement) of water into Resident 43's GT, prior to medication administration as ordered by the physician. 2b. Failing to administer Resident 43's medication and water flushes via gravity (a method of medication administration that uses gravity to pull medication from a piston syringe [a calibrated hollow barrel and a movable plunger used to administer medications and/or water through a GT] in a downward direction through a GT), as indicated in the facility's P&P on Medication Pass via (through) GT. 2c. Failing to administer 5 ml to 10 ml of water to Resident 43's GT between each medication administered, as ordered by the physician and facility's P&P. 3. Ensure LVN 3 administered Resident 68 the complete dose of three of six crushed medications via GT and did not leave significant residues of undissolved medications in the medication cup (plastic translucent cup suitable for dispensing both liquid and dry medications, calibrated from 2.5 ml to 30 ml) in accordance with the physician's orders and professional standard of practice. These deficient practices of administering medications without following physicians' orders, P&Ps, and professional standards of practice placed Resident 22, 43, and 68 at risk of health complications. Cross reference F658, F759 and F760 Findings: 1. A review of Resident 22's admission Record indicated the facility admitted the resident on 11/6/2008 with a readmission dated 5/23/2014. Resident 22's diagnoses included seizure (convulsions) disorder, chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [waste gas made in the body's cells]), dependence on respirator (or ventilator, a machine that helps persons that cannot breathe on their own), tracheostomy (a medical procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and GT. A review of Resident 22's History and Physical (H&P) exam, dated 5/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 8/29/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks such as eating, walking, dressing, bathing, moving in bed, toilet use, and personal hygiene). A review of the Physician's Orders for Resident 22 indicated the following medications: - Keppra (antiseizure medication) 1500 milligrams (mg - a unit of measurement) via GT every 12 hours for seizure disorder ordered on 7/22/2018. - Dilantin (antiseizure medication) 250 mg via GT every 12 hours for seizure disorder, hold GT feeding one hour before and after medication administration, ordered on 10/4/2023. - KCl 20 milliequivalent (mEq - a unit of measurement) 15 ml via GT, dilute with 200 ml water, give daily as supplement, ordered on 7/5/2023. - Colace 250 mg via GT every 12 hours for bowel management, hold for diarrhea, ordered on 4/18/2022. On 10/18/2023 at 8:11 a.m., during a medication administration observation, review of Resident 22's MAR indicated there were eight medications to administer to Resident 22 including the following four medications that LVN 1 prepared: - 15 ml of Keppra and placed it in a medicine cup. - 10 ml of Dilantin and placed it in another medicine cup. - 15 ml of KCL 20 MEQ diluted with 200 ml water in a Styrofoam cup. - One softgel capsule (suited for liquid or semi-solid fillings) of Colace 250 mg 1a. During a medication administration observation on 10/18/2023 at 8:11 a.m., LVN 1 pulled out the bottle of KCl oral solution labeled with Resident 22's name from the medication cart. LVN 1 stated the MAR indicated to administer KCl 20 mEq. Observed the prescription label in the medication bottle indicated KCL 40 mEq (30 ml) via GT daily, dilute with 200 ml water. The label fill date was 9/22/2023. LVN 1 attempted to pour the KCL into a small medicine cup without verifying the dosage in the bottle. During a concurrent observation, interview, and record review on 10/18/2023 at 8:20 a.m., the MAR and KCl bottle label were reviewed with LVN 1 who verified the medication bottle label indicated KCL 40 mEq (30 ml) via GT daily dilute with 200 ml water with a fill date of 9/22/2023. LVN 1 stated the MAR indicated KCl 20 MEQ (15 ml) via GT dilute with 200 ml water daily for supplement. LVN 1 verified the prescription label in the KCl bottle, and the MAR did not match. LVN 1 stated if the label and the MAR did not match, she will notify the charge nurse and check the physician's order. LVN 1 stated LNs were supposed to follow the ten (10) rights of medication administration which included to read the medication label and compare it with the MAR. During a concurrent interview with RN 5 and record review on 10/18/2023 at 8:42 a.m., reviewed the MAR and the prescription label for KCl, RN 5 stated if the label and the MAR did not match, she will check the physician's order and attach a Directions Changed Refer to Chart sticker. RN 5 verified there was no sticker on the medication bottle. LVN 1 and RN 5 stated it was important that the prescription label matched the physician's order and the MAR to ensure Resident 22 received the proper dosage of the medication. 1b. Continuing with the medication administration observation on 10/18/2023 at 8:40 a.m., LVN 1 dispensed Colace 250 mg softgel capsule from a medication bottle into a medicine cup and set it aside. LVN 1 stated the bottle of Colace was a house supply and she was going to place the Colace softgel capsule in hot water to melt the medication. During a concurrent observation, interview, and record review on 10/18/2023 at 8:45 a.m., the MAR and the medication bottle were reviewed with RN 5, who stated the order did not specify the form of the medication (liquid, table, capsule, etc.) to be administered to Resident 22. RN 5 stated the physician should have been notified to clarify the Colace in a liquid form. RN 5 stated if the softgel was placed in hot water, it had the potential to lose the medication potency or efficacy. 1c. During a concurrent observation and interview on 10/18/2023 at 9:05 a.m., LVN 1 added to the Styrofoam cup (with the KCl), the Keppra and the Dilantin and administered to Resident 22 through the GT. When asked, LVN 1 stated and verified that she poured the Dilantin and Keppra into the Styrofoam cup with the KCl diluted in 200 ml of water and administered them together via the GT. LVN 1 stated that she was trained this way on administration of medications to residents with GT but said she should have administered each medication one at a time. LVN 1 stated the medications may not be compatible and mixing them may result on adverse drug reaction placing Resident 22 at risk for serious medical complications. During an interview on 10/18/2023 at 3:00 p.m., LVN 1 stated she failed to follow the facility's P&P and standard of practice by mixing medications instead of giving Resident 22 one medication at a time. LVN 1 stated that she was nervous, and it was her first time a surveyor followed her during medication administration. On 10/19/2023 at 9:21 a.m., the Director of Staff Development (DSD) stated that newly hired LVNs without experience were trained on administering medications and GT administration for seven 12-hour shifts under the guidance of an experienced LN and LVN 1 was signed off as competent on 4/13/2023. The DSD stated the medication administration part on the Competency Orientation Training Checklist and RN/LVN Annual Skills Checklist did not specify competency for medication administration through GT. The DSD stated the Director of Nursing (DON) conducts the LNs annual performance evaluations on the anniversary of the LN date of hire. During an interview on 10/20/2023 at 8:00 a.m., the DON stated medications for GT administration should be given one at a time, to ensure there were no physical or chemical incompatibilities between medications and avoid placing the residents at risk for serious medical complications that may lead to hospitalization or death. The DON stated liquid medications should be administered directly into the GT unless there was a physician's order to dilute with water. The DON stated the prescription label for the KCl should match the MAR and the physician's order unless there was a change of direction. The DON stated the physician should be notified and obtain an order to change the Colace softgel capsule to liquid form for appropriateness during medication administration via GT. The DON stated that placing the softgel in hot water was not acceptable as the medication can lose its potency or efficacy. A review of the facility's P&P titled, Medication Labeling, last reviewed on 1/26/2023, indicated the following: - Prescription medication will have the following information on the label: a. Name, strength, and quantity of drug b. Dose c. Expiration date - If an order is changed on a prescription medication, a Directions changed refer to chart sticker will be placed on medication with the change. A review of the facility's P&P on Medication Pass via GT /Jejunostomy tube (JT, a soft tube inserted during surgery into the small intestine [bowel] through the belly to deliver food and medications), last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to pass medications through the GT / JT. The policy indicated the following: - Follow the 10 Patient Rights of giving medications. - Give medications as ordered one at a time with 5 to 10 ml in between each medication or as per physician order. A review of the facility's P&P titled, Medication Pass, last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to properly complete medication pass. The policy indicated: - Follow the 10 Patient Rights of giving medications. - Check medication against the MAR to be correct. - Give medication one at a time. A review of the facility's P&P policy and procedure titled, 10 Medication Rights, last reviewed on 1/26/2023, indicated as policy statement to make sure the LNs follow the updated guidelines for the patient medication rights. The policy indicated to read the medication label carefully and compare it to the MAR. If there are any doubts, verify with the chart and the Charge Nurse (CN). 2. A review of Resident 43's admission Record indicated the facility originally admitted the resident on 9/7/2016 with diagnoses including chronic respiratory failure, GT, anoxic brain damage (injuries caused by a complete lack of oxygen to the brain, which results in the death of brain cells), acute embolism (obstruction of an artery [type of blood vessel], typically by a clot of blood or an air bubble), and thrombosis (local clotting of the blood in a part of the circulatory system [system that circulates blood through the body: the heart, blood vessels, and blood]). A review of Resident 43's MDS, dated [DATE], indicated Resident 43 rarely or never understood, was unable to make decisions, and required total staff assistance with ADLs. A review of the Physician's Order for Resident 43, indicated the following: - Flush 50 ml of water via GT before and after medication administration and 5 ml to 10 ml in between medications, ordered on 9/9/2016. - Vitamin D 1000 international units (IU - a unit of measurement) via GT every day for supplement, ordered on 1/19/2018. - Tums (medication used to relieve heartburn) 750 mg per tablet, one tablet via GT every 12 hours, ordered on 8/14/2018. - Multivitamins with minerals one tablet via GT every day for supplement, ordered on 4/15/2019. - Vitamin C 500 mg via GT every 12 hours for supplement, ordered on 7/25/2019. - Xarelto (rivaroxaban, blood thinner to treat and prevent blood clots) 10 mg via GT every day to prevent for deep vein thrombosis (DVT - a blood clot in a deep vein, usually in the legs), dated 9/23/2019. On 10/18/2023, at 9:04 a.m. during a medication administration observation and concurrent interview, LVN 2 was outside Resident 43's room reviewing Resident 43's medication administration record (MAR). LVN 2 stated Resident 43 was going to receive the following medications through the GT: - Tums 750 mg - Vitamin D 1000 IU - Multivitamins with minerals one tab - Vitamin C 500 mg - Xarelto 10 mg LVN 2 placed each medication in a medication cup, then proceeded to transfer each medication into separate clear packets and crushed each one using a pill grinder. Then, placed the crushed contents of each packet into separate medicine cups. On 10/18/2023, at 9:20 a.m., continuing with the medication pass observation at bedside, LVN 2 used a piston syringe poured approximately 5 ml to 10 ml of water into five small clear plastic cups containing crushed medications and mixed the contents of each cup separately. 2a. LVN 2 did not administer 50 ml of water through Resident 43's GT as ordered by the physician. 2b. LVN 2 drew up the mixture from one of the five cups using the piston syringe, connected the piston syringe barrel to the GT, and slowly pushed the medication using the syringe plunger instead of allowing the medication. LVN 2 continued to give the remaining four medications and slowly pushing each medication, not following standards of practice and P&P. 2c. LVN 2 continue did not administer 5 ml to 10 ml of water into Resident 43's GT between each medication administered as per physician's order and P&P. On 10/18/2023, at 9:26 a.m., after completing the medication pass, a concurrent interview with LVN 2 and a review of Resident 43's MAR which indicated to flush 50 ml of water via GT before and after medication administration and 5 ml to 10 ml in between medications. LVN 2 stated she forgot to flush Resident 43's GT with 50 ml of water before administering the medications and confirmed not flushing the GT with 5 ml to 10 ml between the five medications. LVN 2 stated it was important to flush a GT prior to administering medications to check for patency (open or unobstructed) and to prevent clogging. LVN 2 explained that since she had a lot of medications to administer, she did not want to take time in flushing water between each medication. LVN 2 stated she sometimes administers water between each medication, but only if the medication is sticky. LVN 2 stated it is important to administer water between each medication to prevent the medications from clogging the GT. Further review of Resident 43's MAR did not indicate Resident 43 had an order for gentle pushes to administer medications and was confirmed by LVN 2. LVN 2 stated she did not administer Resident 43's medication by gravity. During an interview, on 10/20/2023, at 12:05 p.m., the DON stated that prior to medication administration, the nurses needed to review the resident's MAR for instructions on which medications needed to be administered and how the medications were to be administered. The DON stated the GT needed to be flushed with 50 ml of water prior to medication administration and medications needed to be administered one at a time, by gravity. The DON stated it was not appropriate to push medications into the GT with the piston syringe because it could result on the medications splash if the GT dislodged from the syringe or the resident may aspirate (liquid go into the airway) if the medication was pushed fast. The DON stated 5 ml to 10 ml of water is needed to be flushed between each medication to make sure there were no drug interactions and to prevent the GT from clogging. On 10/20/2023, at 4:55 p.m., during an interview, the Medical Director (MD) stated flushing the GT with water before, between, and after medication administration was a standard practice. The MD stated administering water is done to make sure the medication is distributed properly, if water is not flushed between each medication, it was possible residual medication (in the tubing) would not reach its destination. A review of the facility's P&P titled, Gastrostomy Tube Water Flush, reviewed 1/26/2023, indicated the procedure for water flush: - Insert syringe into the end of the GT - Pour water into syringe - Allow water to flow by gravity into stomach - Hold about 12-18 inches (unit of measurement) above the opening - Flush 50 ml prior to medication administration, then flush 5 ml to 10 ml between each medication or per physician's order. A review of the facility's P&P on Medication Pass Via GT / JT, reviewed on 1/26/2023, indicated to flush the tube as ordered before and after medication administration. The P&P further indicated adults are given medications as ordered one at a time with 5 ml to 10 ml in between each medication or as per physician's orders. 3. A review of Resident 68's admission Record indicated the facility admitted the resident on 10/28/2019 with diagnoses including anoxic brain damage, tracheostomy, and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 68's H&P exam, dated 3/1/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 68's MDS, dated [DATE], indicated the resident had severely impaired cognition, had a GT for feeding, and was dependent on staff with all ALDs. A review of the Physician's Orders for Resident 68 indicated the following medications: - Colace (stool softener) 100 mg via GT, every 12 hours for bowel management, hold for loose stool, ordered on 4/26/2023. - Glycopyrrolate (Robinul, anticholinergic medication) 2 mg via GT, every 8 hours for secretions, ordered on 3/1/2023. - Magnesium oxide (mineral supplement used to prevent and treat low amounts of magnesium in the blood) 400 mg via GT every day, ordered on 3/1/2023. - Vitamin D 2000 IU via GT every day for supplement ordered on 3/1/2023. - Clonidine (to treat hypertension) 0.2 mg via GT twice a day ordered on 3/1/2023. - Tizanidine (Zanaflex, muscle relaxant) 2 mg via GT three times a day ordered on 3/1/2023. A review of Resident 68's Care Plan developed on 4/17/2023 for the resident's excessive (respiratory) secretions requiring Robinul every 8 hours, had a goal for the resident to always have patent (unobstructed) airway. The interventions included to give medications as ordered. On 10/18/2023, at 8:14 a.m. during a medication administration observation LVN 3 prepared Resident 68's morning medications, as follows: - Colace 100 mg, 1 tablet - Robinul 2 mg, 1 tablet - Magnesium oxide 400 mg, 1 tablet - Vitamin D3 1000 IU, 1 tablet - Clonidine 0.2 mg, 1 tablet - Zanaflex 2mg 1 tablet At 8:18 a.m., LVN 3 crushed each tablet in a separate plastic packet and placed each crushed medication into separate medicine cups. At 8:23 a.m., LVN 3 placed medicine tray with the six medication cups on top of overbed side table and poured about 10 ml of water inside each medicine cup. At 8:27 a.m., LVN 3 attached the piston syringe hollow barrel to the GT and removed the syringe plunger before administering the medications. LVN 3 shook each medicine cup before pouring each content in the syringe barrel allowing the content to go through the GT by gravity. At 8:36 a.m., during an interview, LVN 3 stated she completed medication pass for Resident 68. There were three medicine cups with residual crushed medications. LVN 3 stated the cups contained Vitamin D, magnesium oxide, and Robinul. LVN 3 stated some of the crushed tablets stuck to the bottom of the cup. LVN 3 stated she did not know how much of the medicine was left in the three medicine cups, but it seemed a lot. LVN 3 stated she was going to dispose of them. At 8:38 a.m., LVN 3 proceeded to sign Resident 68's MAR indicating the six medications were given. During an interview on 10/20/2023 at 4:06 p.m., the DON stated that after administering medication, the LNs must check the medicine cup to ensure there is no medication remaining and the residents receive the ordered dose. The DON stated LNs may use apple sauce so the crushed medications would not stick on the bottom of the medicine cup and may use a spoon or a coffee stirrer to stir the medication. The DON stated Resident 68 did not receive the ordered dose of Robinul and it was possible for Resident 68 to have increased respiratory secretions, which may lead to respiratory distress, coughing, or aspiration. On 10/20/2023 at 4:55 p.m., during an interview, the MD stated sometimes anticholinergic medications are given due to the excess secretion or for bradycardia (slow heart rate). The MD stated when anticholinergics are not administered correctly the resident may need to be suctioned (removal of secretions from the airway using a suction machine). A review of the facility's policy and procedure titled, Medication Rights, reviewed and approved 1/26/2023, indicated it is the facility's policy to make sure that licensed nurses follow the updated guidelines for the Patient Medication Rights. The procedure indicated: 3. Right Dose - compare the dose of the medication to the MAR. 6. Right Documentation - the documentation of the medication must be done at the time that you give the medications. A review of the facility's policy and procedure on Medication Pass via GT / JT, reviewed on 1/26/2023, indicated it was the facility's policy to make sure that nursing would follow the policy of giving medications. The procedures indicated to ensure all medication is given and not remaining in the cup.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety for the following: 1. An open bottle of Worcestershire sauce with received date of 9/10/2022 and best by date of 6/25/2024 was without an open date. 2. An open [NAME] Red cooking wine with received date of 5/28/2022 and best by date of 10/9/2022 was without an open date. 3. Flavor glow (Dark) with no received date, with open date of 9/8/2022, and no best by date. 4. Corn bread mix with no received date, with open date of 10/3/2023, and no best by date. 5. Cayenne Pepper Hot 40,00 [NAME] with no received date, no open date, and with best by date of 9/2/2022. 6. Ground ginger with no received date, no open date, and with best by date of 3/15/2023. 7. Ground mustard with no received date, no open date, and with best by date of 5/28/2023. 8. Ground nutmeg with no received date, no open date, and with best by date of 8/30/2023. 9. Plain breadcrumbs with received date of 9/15/2023, no open date, and no best by date, 10. Mexican style oregano received date of 12/3/2022, no open date, and no best by date. 11. Bran flakes with received date of 12/6/2022, no open date, and no best by date. 12. Italian seasoning with received date of 12/30/2022, no open date, and no best by date. 13. A bag of marshmallows with best by date of 7/28/2023. 14. Half of an avocado wrapped in saran wrap without a date. 15. Individual packs of butter on a Ziplock bag with open date of 9/6/2023 with no received date, no open date, and no best by date. These deficient practices had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 10/16/2023, at 8:04 a.m., the Dietary Manager (DM) stated the condiments should have been placed with the received date, open date, and best by date to ensure that they were using non-expired food condiments and seasonings. The DM stated the bran flakes container should have been labeled with the received date, open date, and best buy date to ensure the bran flakes were not expired. The DM stated the staff should place the received date, open date, and best buy date for all food products transferred to other containers to know when to discard them. The DM stated the half of the avocado wrapped in saran wrap should have been dated to know when to discard them. The following were observed: 1. An open bottle of Worcestershire sauce with received date of 9/10/2022 and best by date of 6/25/2024 was without an open date. 2. An open [NAME] Red cooking wine with received date of 5/28/2022 and best by date of 10/9/2022 was without an open date. 3. Flavor glow (Dark) with no received date, with open date of 9/8/2022, and no best by date. 4. Corn bread mix with no received date, with open date of 10/3/2023, and no best by date. 5. Cayenne Pepper Hot 40,00 [NAME] with no received date, no open date, and with best by date of 9/2/2022. 6. Ground ginger with no received date, no open date, and with best by date of 3/15/2023. 7. Ground mustard with no received date, no open date, and with best by date of 5/28/2023. 8. Ground nutmeg with no received date, no open date, and with best by date of 8/30/2023. 9. Plain breadcrumbs with received date of 9/15/2023, no open date, and no best by date, 10. Mexican style oregano received date of 12/3/2022, no open date, and no best by date. 11. Bran flakes with received date of 12/6/2022, no open date, and no best by date. 12. Italian seasoning with received date of 12/30/2022, no open date, and no best by date. 13. A bag of marshmallows with best by date of 7/28/2023. 14. Half of an avocado wrapped in saran wrap without a date. 15. Individual packs of butter on a Ziplock bag with open date of 9/6/2023 with no received date, no open date, and no best by date. During an interview on 10/20/2023, at 8:40 a.m., the Director of Staff Development (DSD) stated the kitchen staff should have placed an open date, received date, and best by date on food products as per policy. The DSD stated upon finding those items missing with those days, those food products should have been discarded. The DSD stated the deficient practices had a potential for food poisoning. During an interview on 10/20/2023, at 9:36 a.m., the Director of Nursing (DON) stated the staff should have done a monitoring at least once a week to check for supply expiration dates, open dates, and best by dates in order not to harm the patient for expired sauces and food products. The DON stated the kitchen staff should have removed all the condiments without the appropriate label dating. A review of the facility's recent policy and procedure titled, Labeling and Dating of Foods, last reviewed on 1/26/2023, indicated all food items in the storeroom, refrigerator, and freezer needed to be labeled and dated. Food delivered to the facility needs to be marked with a received date. Newly opened food items will need to be closed and labeled with an open date and used by date that follow manufacturers guidelines. Produce is to be dated with received date. Leftovers will be covered, labeled, and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records that are complete and accurate documentation for five of seven sampled residents (Resident 22, 31, 94, 99, and 38), by failing to: 1. Ensure respiratory therapists signed the respiratory therapy Documentation - Charting Record after administering medications for Residents 22, 31, and 94. 2. Ensure the intravenous (IV) Medication Administration Record (MAR) was completed for one out of three residents investigated under resident records (Residents 94). 3. Ensure respiratory therapists signed the respiratory therapy Documentation - Charting Record after providing treatment as ordered by the physician for Resident 99 and 38. These deficient practices had the potential to result in inadequate management of the residents' health condition and the medical records containing inaccurate documentation. Findings: a.1. A review of Resident 22's Record of admission indicated the facility admitted the resident on 11/6/2008 and readmitted on [DATE] with diagnoses including convulsion (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review if Resident 22's History and Physical dated 5/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/29/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 22's respiratory therapy Documentation - Charting Record for 10/2023 indicated a missing initial on 10/11/2023 to change hand-held nebulizer (HHN - a device that converts a medication in liquid form to mist to add moisture and help control respiratory symptoms) every Wednesday and as needed. a.2. A review of Resident 31's Record of admission indicated the facility admitted the resident on 8/10/2010 and readmitted the resident on 5/21/2022 with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 31's History and Physical dated 9/28/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 31's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/13/2023, indicated the resident had persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). a.3. A review of Resident 94's Record of admission indicated the facility admitted the resident on 3/20/2023 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 94's History and Physical dated 6/28/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 94's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/6/223, indicated the resident had persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 94's Physician's Orders indicated peripherally inserted central catheter (PICC - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) line flushing, caring, dressing change per facility protocol by Registered Nurse (RN) on duty. A review of Resident 94's Intravenous Therapy Record for 10/2023 did not indicate the RN initials on the following: 1. Zosyn (an antibiotic used to treat many different infections caused by bacteria) 3.375 grams (gms - a unit of measurement) every six hours with a stop date of 10/17/2023: a. 10/5/2023 at 12 p.m. and 6 p.m. b. 10/14/2023 at 12 a.m. and 6 a.m. 2. Saline lock flush: flush with ten (10) milliliters (ml- a unit of measurement) normal saline (NS) before and after medication: a. 10/5/2023, 10/6/2023, 10/7/2023, 10/8/2023, 10/9/2023 during 7 a.m. to 7 p.m. shift. b. 10/4/2023, 10/5/2023, 10/6/2023, 10/7/2023, 10/8/2023, 10/9/2023, 10/10/2023, 10/11/2023 during 7 p.m. to 7 a.m. shift. 3. Heparin flush (used to clean out an IV catheter to help prevent blockage in the tube after IV infusion) five ml final flush on 10/5/2023 and 10/6/2023 during 7 a.m. to 7 p.m. shift. 4. Tubing change frequency intermittent every 24 hours on 10/1/2023, 10/2/2023, 10/3/2023, 10/4/2023, 10/5/2023, 10/5/2023, 10/6/2023, 10/9/2023, 10/10/2023, 10/11/2023, 10/12/2023, 10/13/2023, 10/14/2023, 10/15/2023, 10/16/2023. During a concurrent interview and record review on 10/16/2023 at 12:30 p.m., Respiratory Therapist 3 (RT 3) verified that there were missing initials on Residents 22, 31, and 94's Documentation-Medication Record for 10/11/2023 to change handheld nebulizer (HHN - a device that converts a medication in liquid form to mist, so the medication can be inhaled into the lungs) set up every Wednesday and as needed. RT 3 stated that he changed the HHN set up for Residents 22, 31, and 94 on 10/11/2023 but forgot to document. RT 3 stated that he should have documented in the Documentation-Medication Record after completion of task for accuracy of the medical record and for other staff to know the last time they were changed. During a concurrent interview and record review on 10/20/2023 at 6:06 p.m., the Director of Respiratory Therapy (DRT) verified there were missing initials on Residents 22, 31, and 94's Documentation-Medication Record for 10/11/2023 to change HHN set up every Wednesday and as needed. The DRT stated that RT 3 should have documented in the Documentation-Medication Record for accuracy of the medical record and for other staff to know the last time they were changed. b. During a concurrent interview and record review on 10/18/2023 at 10:38 a.m., reviewed Resident 94's IV Therapy Record with Registered Nurse 2 (RN 2). RN 2 stated that RNs were supposed to document their initials on the IV Therapy Record once the medications were administered, and other catheter care were done. RN 2 verified the missing initials on the aforementioned dates and times. RN 2 stated that she was working on 10/5/2023 and forgot to indicate her initials. RN 2 stated it was important to sign the IV Therapy Record to ensure accuracy of Resident 94's medical record. During a concurrent interview and record review on 10/19/2023 at 9:17 a.m., reviewed Resident 94's IV Therapy Record with RN 2 and RN 3. RN 3 stated that RNs nurses were supposed to document their initials on the IV Therapy Record once the medications were administered and other catheter care were done. RN 3 verified the missing initials on the aforementioned dates and times. RN 2 stated that he was working on 10/6/2023 and forgot to indicate his initials on the catheter maintenance orders for accuracy of Resident 94's medical record. RN 3 stated it was important to sign the IV Therapy Record to ensure accuracy of Resident 94's medical record. During a concurrent interview and record review on 10/19/2023 at 10:38 a.m., the Minimum Data Set Coordinator (MDS) verified that there were multiple missing initials on the IV Therapy Record. The MDSC stated that the RNS should have indicated their initials after catheter care and IV medication administration to ensure accuracy of Resident 94's medical record and prevent delay in the provision of necessary care and services the resident needs. A review of the facility's policy and procedure titled, Respiratory MAR Documentation, last reviewed on 1/26/2023, indicated a policy statement to ensure that proper documentation in the Medication Administration Record (MAR) is complete and accurate. The policy indicated the respiratory therapist must follow the ten rights of giving medications and must sign the MAR after administering medications. A review of the facility's policy and procedure titled, Central Venous Catheters (CVCs): Care and Maintenance, last reviewed 1/26/2023 indicated the following: 1. Document dressing change including date, time, and site. 2. NS lock is part of MAR documentation. 3. All procedures must be documented. c.1. A review of Resident 99's Record of admission indicated the facility admitted the resident on 4/25/2023 with diagnoses including chronic respiratory failure, dependence on respirator (ventilator), and tracheostomy. A review of Resident 99's History and Physical, dated 4/26/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 99's MDS, dated [DATE], indicated the resident had modified independence (some difficulty in new situations only) cognitive skills for daily decision making. The MDS indicated the resident required total assistance with bed mobility, dressing, eating (tube feeding), toilet use, and personal hygiene with physical assist from staff. The MDS indicated respiratory treatments including oxygen therapy, suctioning, tracheostomy care, invasive mechanical ventilator (ventilator or respirator) were performed while the resident was a resident of the facility. A review of Resident 99's Physician Orders, dated 4/25/2023, indicated the following orders: - Change closed suction catheter system (protected suction tube catheter inside a sterile plastic sleeve) every Monday and Thursday - Change metered dose inhaler (MDI) adapters (directs medication mainstream for ventilator residents) every month - Pulse oximetry (used to measure the amount of oxygen in the bloodstream) every shift - Tracheostomy care every shift - Change vent circuit (tubing that connects the ventilator to the resident as well as any devices that may be connected to the circuit) every monthly During a concurrent interview and record review of Resident 99 and Resident 38's respiratory Documentation - Charting Record for the month of 10/2023, on 10/16/2023 at 2:50 p.m., RT 8 stated after the treatment they are supposed to sign the respiratory Documentation - Charting Record. RT stated if the record was not signed, it was not done. RT stated Resident 99 had missing initials scheduled for 7 p.m. to 7 a.m. shift for: - Change closed suction catheter system every Monday and Thursday on 10/2/2023 and 10/16/2023. - Change MDI adaptor every month on 10/1/2023 - Pulse oximetry every shift on 10/2/2023 - Tracheostomy care every shift on 10/2/2023 - Change vent circuit every monthly on 10/1/2023 A review of the facility's policy and procedure titled, Respiratory MAR Documentation, last reviewed on 1/26/2023 indicated a policy statement to ensure that proper documentation in the MAR is complete and accurate. The policy indicated the respiratory therapist must follow the ten rights of giving medications and must sign the MAR after administering medications. c.2. A review of Resident 38's Record of admission indicated the facility admitted the resident on 8/23/2023 with diagnoses including chronic respiratory failure, dependence on respirator (ventilator), and tracheostomy. A review of Resident 38's MDS, dated [DATE], indicated the resident required total assistance with bed mobility, dressing, eating (tube feeding), toilet use, and personal hygiene with physical assist from staff. The MDS indicated respiratory treatments including oxygen therapy, suctioning, tracheostomy care, invasive mechanical ventilator (ventilator or respirator) performed while the resident was a resident of the facility. A review of Resident 38's Physician Orders, dated 8/23/2023, indicated the following orders: - Tracheostomy care every shift - Change closed suction catheter system every Monday and Thursday - Ventilator dependent: change inner cannula every day 8 a.m. to 8 p.m. A review of Resident 38's care plan titled, Presence of tracheostomy, dated 8/24/2023, indicated the resident with goals of maintaining a patient airway at all times including interventions to render trach care every shift, and respiratory care services and oxygen as per physician order. During a concurrent interview and record review of Resident 99 and 38's respiratory Documentation - Charting Record for the month of 10/2023, on 10/16/2023 at 2:50 p.m., RT 8 stated after the treatment they are supposed to sign the respiratory Documentation - Charting Record. RT stated if the record was not signed, it was not done. RT stated Resident 38 had missing initials scheduled for: - Tracheostomy care every shift, 7 a.m. to 7 p.m. shift on 10/12/2023 and10/14/2023 - Tracheostomy care every shift, 7 p.m. to 7 a.m. shift on 10/2/2023 and 10/9/2023 - Change closed suction catheter system every Monday and Thursday, 7 a.m. to 7 p.m. on 10/2/2023, 10/5/2023, 10/9/2023, and 10/12/2023. - Ventilator dependent: change inner cannula every day 8 a.m. to 8 p.m. on 10/12/2023 A review of the facility's policy and procedure titled, Respiratory MAR Documentation, last reviewed on 1/26/2023 indicated a policy statement to ensure that proper documentation in the MAR is complete and accurate. The policy indicated the respiratory therapist must follow the ten rights of giving medications and must sign the MAR after administering medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. During concurrent interview and record review on 10/19/2023 at 10:37 a.m., the Infection Preventionist (IP) reviewed the human resource (HR) file for Certified Nurse Assistant 4 (CNA 4), Licensed Vocational Nurse 18 (LVN 18), and stated that the record did not indicate the date when the annual N95 fit testing was performed. IP also stated that the fit testing has to be performed annually and the fit testing record has to be kept in the employee HR files. The absent date for the fit testing created the potential for staff to be wearing N95 respirators that were not properly fitted, which could lead to the spread of Covid-19 around the facility. During concurrent interview and record review on 10/20/2023 at 11:20 a.m., Director Staff Development (DSD), reviewed the employee files for CNA 4, LVN 18 and IP, and stated that she performs the fit testing for employees in the facility on their birthday month. She stated that, by policy, fit testing has to have a date for when it was performed, and that omitting date may lead to an infection control problem. During concurrent interview and record review on 10/20/2023 at 03:08 p.m., Director of Nursing (DON), stated that fit testing has to be done annually and the fit testing record has to have the date as well as the type of mask used. DON also stated that the missing date may lead to an infection issue in the facility. A review of the facility's policy and procedure titled, Fit testing, reviewed 1/26/2023, indicated, A fit testing form will be completed, signed, and dated by DSD, and maintained in the employee HR file. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for five of six sampled residents (Residents 54, 16, 313, 5, and 95) by failing to: 1. Ensure Residents 54, 16, and 313's irrigation trays (used to flush and administer food and medications to residents with feeding tube [tubes mainly inserted into the gastrointestinal tract to provide patient with a route for enteral nutrition]) were discarded and replaced with new irrigation trays indicating the current date it was last changed. 2. Ensure Resident 5's irrigation tray was labeled with the current date it was last changed. 3. Ensure Resident 95's Yankauer catheter (a suction tool used to remove secretions, such as mucus, from a person's airway) was labeled with a date when it was last changed. 4. Ensure Residents 19, 25, 43, and 105's Yankauer suction indicated the date when it was last changed. 5. Ensure Resident 27's cool aerosol tubing was not touching the floor. 6. Ensure the facility follow its own policy related to annual N95 respirator fit testing. These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents. Findings: 1.a. A review of Resident 54's Record of admission indicated the facility admitted Resident 54 on 1/4/2017 and the facility readmitted Resident 54 on 1/26/2023, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and gastrostomy (a surgical procedure used to insert a tube, often referred to as a g-tube, through the abdomen and into the stomach). A review of Resident 54's History and Physical (H&P), dated 1/27/2023, indicated Resident 54 did not have the capacity to understand and make decisions. A review of Resident 54's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/11/2023, indicated Resident 54 had rarely to never had the ability to make self-understood and understand others. The MDS also indicated Resident 54 was on respiratory treatments such as oxygen therapy (a treatment that provides supplemental, or extra oxygen), suctioning (the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place), tracheostomy care (a procedure performed routinely to keep the tracheostomy dressing, ties and straps ,and surrounding area clean to reduce the introduction of bacteria into the trachea and lungs), and invasive mechanical ventilator (a machine that takes over the work of breathing when a person is not able to breathe enough on their own). The MDS also indicated Resident 54 was on a feeding tube. During a concurrent observation and interview on 10/16/2023, at 9:58 a.m., observed with Licensed Vocational Nurse 5 (LVN) 5, Resident 54's irrigation tray was dated 10/14/2023. LVN 5 stated the irrigation tray, dated 10/14/23, should be changed to prevent infection. 1.b. A review of Resident 16's Record of admission indicated the facility admitted Resident 16 on 5/10/2019, with diagnoses including tracheostomy, gastrostomy, and quadriplegia (paralysis of all four limbs). A review of Resident 16's H&P, dated 5/6/2023, indicated Resident 16 did not have the capacity to understand and make decisions. A review of Resident 16's MDS, dated [DATE], indicated Resident 16 had rarely to never had the ability to make self-understood and understand others. The MDS also indicated Resident 54 was on respiratory treatments such as oxygen therapy, suctioning, and tracheostomy care. The MDS also indicated Resident 16 was on a feeding tube. During a concurrent observation and interview on 10/16/2023 at 9:58 a.m., observed with LVN 5 Resident 16's irrigation tray was dated 10/14/2023. LVN 5 stated the irrigation tray should be changed, the irrigation tray was dated 10/14/23 to prevent infection. 1.c. A review of Resident 313's Record of admission indicated the facility admitted Resident 313 on 5/23/2022 and the facility readmitted Resident 313 on 10/10/2023, with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. A review of Resident 313's H&P, dated 10/14/2023, indicated Resident 313 did not have the capacity to understand and make decisions. A review of Resident 313's MDS, dated [DATE], indicated Resident 313 was on feeding tube and on a therapeutic diet. The MDS indicated Resident 313 was on respiratory treatments such as oxygen therapy, suctioning, tracheostomy care, and on invasive mechanical ventilator. During a concurrent observation and interview on 10/16/2023, at 9:46 a.m., observed with Licensed Vocational Nurse 8 (LVN 8) Resident 313's irrigation tray was dated 10/14/2023. LVN 8 stated the irrigation tray should have been changed daily to prevent infection. 2. A review of Resident 5's Record of admission indicated the facility admitted Resident 5 on 5/2/2019 and the facility readmitted Resident 5 on 6/9/2019, with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. A review of Resident 5's H&P, dated 6/1/2023, indicated Resident 5 did not have the capacity to understand and make decisions. A review of Resident 5's MDS, dated [DATE], indicated Resident 5 had rarely to never had the ability to make self-understood and understand others. The MDS also indicated Resident 5 was on respiratory treatments such as oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator. The MDS also indicated Resident 5 was on a feeding tube. During a concurrent observation and interview on 10/16/2023, at 10:15 a.m., observed with LVN 5 Resident 5's irrigation tray was not labeled with a date. LVN 5 stated the irrigation tray should be dated to know when to change them and for infection control. A review of the facility's recent policy and procedure titled, Irrigation Bottles, last revised on 1/26/2023, indicated irrigation bottles will be changed daily by Certified Nursing Assistant, or Primary Nurse. Irrigation bottles will be labeled with the patient's last name, date, and room/bed#. 3. A review of Resident 95's Record of admission indicated the facility admitted Resident 95 on 3/5/2023 and the facility readmitted Resident 95 on 4/5/2023, with diagnoses including chronic respiratory failure, tracheostomy, dependence on respirator (a device that forces air into a person's lungs when the person cannot breathe independently and needs help to breathe). A review of Resident 95's H&P, dated 9/5/2023, indicated Resident 95 had the capacity to understand and make decisions. A review of Resident 95's MDS, dated [DATE], indicated Resident 85 had the ability to make self-understood and understand others. The MDS also indicated Resident 95 was on respiratory treatments such as oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator. During a concurrent observation and interview on 10/16/2023, at 10:50 a.m., observed with LVN 5, Resident 95's Yankauer was not dated and with dried up greenish secretions on the tip. LVN 5 stated the Yankauer should have been dated for infection control issues. During an interview on 10/20/2023, at 8:40 a.m., the Director of Staff Development (DSD) stated the staff should have changed the irrigation tray every night, the deficient practice had the potential for spread of infection. The DSD stated the staff should have labeled the irrigation tray with the name and date it was changed to make sure they are using the right irrigation tray to the right patient. The DSD stated they change the suction tubing every Mondays and Wednesdays. The DSD stated the Yankauer tubing was a part of the suction tubing, and it carries the date it was changed on the tubing. The DSD stated deficient practice of not dating the tubing to indicate the Yankauer date changed has the potential for spread of infection. During an interview on 10/20/2023, at 9:36 a.m., the Director of Nursing (DON) stated the staff should have changed the irrigation trays daily to prevent infection. The DON stated the purpose of placing the name and date on the irrigation tray was to prevent cross contamination. The DON stated the Yankauer takes the date change of the suction tubing. The DON stated they in-serviced the staff to change the tubing together with the Yankauer if the resident uses them. A review of the facility's recent policy and procedure titled, Irrigation Bottles, last reviewed on 1/26/2023, indicated irrigation bottles will be changed daily by Certified Nursing Assistant, or primary Nurse. Irrigation bottles will be labeled with the Patient's name, date, and room/bed#. A review of the facility's recent policy and procedure titled, Equipment Changing-Shift Responsibilities, last reviewed on 1/26/2023, indicated all tubing, drainage bags, masks, and adapters: Change every (q) 7 days and if necessary (PRN). A review of the facility's recent policy and procedure titled, Suction Canister and Tubing Change, last reviewed on 1/26/2023, indicated the purpose of this policy is to provide a guideline for the routine and PRN change of suction canisters and their tubing. The suction canister tubing will be labeled with the date it was changed. 4.a. A review of Resident 19's Record of admission indicated the facility admitted the resident on 7/17/2009 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 19's History and Physical, dated 2/22/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 19's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). 4.b. A review of Resident 25's Record of admission indicated the facility admitted the resident on 8/11/2023 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 25's History and Physical, dated 9/19/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 25's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff with all ADLs. 4.c. A review of Resident 105's Record of admission indicated the facility admitted the resident on 8/24/2023 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 105's History and Physical, dated 9/16/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 105's MDS, dated [DATE], indicated the resident had persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings) and was totally dependent on staff with all ADLs. 4.d. A review of Resident 43's Record of admission indicated the facility admitted the resident on 9/7/2016 with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 43's History and Physical, dated 9/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 43's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff with all ADLs. During a concurrent observation and interview on 10/16/2023 at 10:11 a.m., Respiratory Therapist 1 (RT 1) verified Resident 43's Yankauer suction catheter did not indicate the date when it was last changed. RT 1 stated Yankauer suction catheters were changed every day during the 7 p.m. to 7 a.m. shift. RT 1 stated the Yankauer suction catheters should indicate the date so staff would be aware when they were last changed. RT 1 stated it was an infection control issue and placed the resident at risk for acquiring infection. During a concurrent observation and interview on 10/16/2023 at 11:50 a.m., Respiratory Therapist 2 (RT 2) verified Resident 19's, 25's, and 105's Yankauer suction catheters did not indicate the date when they were last changed. RT 2 stated Yankauer suction catheters were changed every day during the 7 p.m. to 7 a.m. shift. RT 2 stated the Yankauer suction catheters should indicate the date so staff would be aware when they were last changed. RT 2 stated it was an infection control issue and placed the residents at risk for acquiring infection. 5. A review of Resident 27's Record of admission indicated the facility admitted the resident on 8/11/2023 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 27's History and Physical, dated 8/22/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 27's, dated 8/2/2023, indicated the resident had an intact cognition and was totally dependent on staff with all ADLs. A review of Resident 27's Physician Order indicated to change vent circuit (a tubing that connects the ventilator [also known as a breathing machine, a life-support system used to maintain adequate lung function in patients who are critically ill] to a patient) monthly and as needed soiled or damp. A review of Resident 27's care plan on presence of tracheostomy potential for infection and aspiration initiated on 1/17/2023 last reviewed on 10/2023 indicated a goal the resident will be free of any signs and symptoms of aspiration at all times. During a concurrent observation and interview on 10/16/2023 at 2:20 p.m., Respiratory Therapist 6 (RT 6) verified that Resident 27's circuit tubing was touching the floor. RT 6 stated the tubing should not be touching the floor. RT 6 stated it was an infection control issue and placed Resident 27 at risk for acquiring infection. During an interview on 10/19/2023 at 11:46 a.m., the Director of Respiratory Therapy (DRT) stated that Yankauer suction catheter was supposed to be changed every day. The DRT stated the date should be indicated on the sleeve or packaging so the staff would know when it was last changed. The DRT stated circuit tubing should not be touching the floor. The DRT stated it was an infection control issue and placed the residents at risk for acquiring infection. A review of the facility's policy and procedure titled, Suction Canister and tubing Change, last reviewed on 1/26/2023, indicated suction tubing will be labeled with the date it was changed. A review of the facility's policy and procedure titled, Infection Control Program, last reviewed on 1/26/2023, indicated the Infection Control Program has policies and procedures to prevent transmission of disease and infections within the facility. The policy indicated to monitor staff performance to ensure policies and procedures for preventing the spread and occurrence of infection are properly executed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained the resident ' s dignity for one of the six sampled residents (Resident 4) by failing to ensure the resident ' s urinary collection bag was covered with a privacy bag. This deficient practice had the potential to negatively affect the self-esteem and self-worth of Resident 4. Findings: A review of Resident 4 ' s Record of admission indicated the facility admitted the resident on 10/20/2021 and readmitted her on 5/6/2023 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into blood or eliminate enough carbon dioxide from the body), type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high), and dependence on a ventilator (a device for maintaining artificial respiration). A review of admission History and Physical dated 5/6/2023 indicated that the resident had the capacity to understand and make decisions. A review of Resident 4 ' s Minimum Data Set ( MDS-a standardized assessment and care screening tool) dated 6/29/2023 indicated that Resident 4 could not walk and required two-person extensive assistance(resident involved in activity, staff provide weight-bearing support) with mobility, transferring, dressing, toileting, and personal hygiene. On 8/31/2023 at 12 p.m., during observation of wound care in room [ROOM NUMBER] with Licensed Vocational Nurse 6 (LVN 6), observed Resident 4's urine bag hanging on the left side of the bed frame with yellow urine. LVN 6 stated that the urinary drain bag was missing a privacy bag. On 8/31/2023 at 12:02 p.m., during an interview with Certified Nursing Assistant 3 (CNA 3), assigned to care of Resident 4, CNA 3 stated the urinary collection bag had to be covered for dignity. CNA 3 stated she will cover the Resident 4 ' s urinary bag. On 8/31/2023 at 2:28 p.m., during an interview, Licensed Vocational Nurse 7 (LVN 7) stated a bag must cover the urine collection bag for privacy. LVN 7 stated missing privacy cover may affect residents ' dignity. On 8/31/2023 at 2:49 p.m. during an interview, [NAME] President of Operation (VP) stated facility provides dignity bags for privacy outside and inside residents ' rooms for dignity of the resident. A review of the facility ' s policy and procedure titled, Privacy cover for Urinary Drain Bags, reviewed 6/1/2023, indicated, Residents who have a urinary catheter with a drainage bag will use Privacy Cover over drainage bag to provide dignity and privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a call light (device used by the patient to signal their need for assistance from medical staff) was provided to three of the six sampled residents (Residents 1, 2, and 3). This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and increased the risk of worsening the residents ' health conditions. Findings: 1. A review of Resident 1 ' s Record of admission indicated the facility admitted Resident 1 on 9/23/2023 with diagnoses including encephalopathy (damage or disease that affects the brain), unspecific convulsion (a medical event in which nerve cell activity in the brain is disrupted, causing muscles to involuntary contract and spasm), and dysphasia (difficulty swallowing). A review of Resident 1 ' s of Annual Physical and History , dated 9/19/2022 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 7/10/2023, indicated Resident 1 could not walk and required two- persons assistance( resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, toileting, and personal hygiene. The MDS also indicated Resident 1 required tracheostomy care(suction of tracheotomy tube[an opening created at the front of the neck so a tube can be inserted into the trachea to help paint breath]) and oxygen therapy (a treatment that provides patient with extra oxygen to breath). On 8/31/2023 at 10:52 a.m., during observation in room [ROOM NUMBER], Resident 1 was lying in bed. There was no call light observed within the resident's each. 2. A review of Resident 2 ' s Record of admission indicated the facility admitted Resident 2 on 12/29/2021 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), unspecific convulsion (a medical event in which nerve cell activity in the brain is disrupted, causing muscles to involuntary contract and spasm), and type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high). A review of Resident 2 ' s Annual Physical and History, dated 12/9/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 6/29/2023, indicated the resident could not walk and required two- persons assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, toileting, and personal hygiene. The MDS also indicated the resident required tracheotomy care(suction of tracheotomy tube[an opening created at the front of the neck so a tube can be inserted into the trachea to help paint breath]) and oxygen therapy (a treatment that provides patient with extra oxygen to breath). On 8/31/2023 at 11:15 a.m., during an observation, Resident 2 was lying in bed. There was no call light observed within the resident's reach. 3. A review of Resident 3 ' s Record of admission indicated the facility admitted the resident on 12/16/2021 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into blood or eliminate enough carbon dioxide from the body), unspecific convulsion (a medical event in which nerve cell activity in the brain is disrupted, causing muscles to involuntary contract and spasm), and aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension). A review of Resident 3 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 6/18/2023, indicated the resident could not walk and required two- persons assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident had severely impaired cognition (when the resident has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The resident required tracheotomy care(suction of tracheotomy tube[an opening created at the front of the neck so a tube can be inserted into the trachea to help paint breath]) and oxygen therapy (a treatment that provides patient with extra oxygen to breath). On 8/31/2023 at 11:16 a.m., during observation, Resident 3 was lying in bed. There was no call light observed within the resident's reach. On 8/31/2023 at 11:17 a.m. , during a concurrent observation and interview, LVN 5 stated that she the call lights are not within reach of Residents 1, 2, or 3. LVN 5 found 1 regular and 2 adaptive call lights on the blood oxygen saturation monitor (device to monitor amount of oxygen in the blood) stands next to the residents' beds. LVN 5 placed the call lights within reach of each resident. LVN 5 stated that each resident is supposed to have a call light within reach to be able to call for help. LVN 5 also stated that the absence of a call light has the potential to result in a resident not receiving the care they need on time. During an interview on 8/1/2023 at 2:28 p.m., LVN 7 stated all residents are supposed to have a call light according to the facility policy. LVN 7 stated a possible outcome of not having a call light wihin reach could be the worsening of a resident ' s condition because they could not get help on time. During an interview on 8/31/2023 at 2:35 p.m., RN 1 stated that a call light has to be within reach of each resident in the facility so that residents can get help when they need it. RN 1 stated it could be a safety and emotional concern if the resident could not reach help when they needed it. During an interview on 8/31/2023 at 2:49 p.m., the VP stated that every resident is supposed to have a call light within reach and that the absence of a call light puts the residents at risk of not having their needs met. A review of the policy and procedure titled, Call light, reviewed 2/1/2023, indicated The call light will be placed within their reach . Call light will be monitored for positioning by Licensed Nurses and Certified Nursing Assistants during rounds and after treatments.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent formation and progression of a pressure injury (decubitus ulcer, an injury to skin and underlying tissue due to prolonged pressure over a bony structure) for one of four sampled residents (Resident 1) by: 1. Failing to adjust the low air loss mattress (LALM, a mattress to provide airflow to help skin dry, as well as to relieve pressure) based on the patient's weight distribution for Resident 1 who had moisture-associated skin damage (MASD, is caused by prolonged exposure to various sources of moisture, including urine and stool, perspiration, wound exudate, mucus, saliva, and their contents) on the buttocks and thighs and unstageable pressure injury (an ulcer that has full thickness tissue loss but is either covered by necrotic [dead] tissue) in the coccyx (tailbone). 2. Failing to turn Resident 1 who had MASD on the buttocks, inner thighs, and unstageable pressure injury in the coccyx every two hours to prevent worsening of pressure injuries. These deficient practices had the potential to cause worsening of Resident 1's pressure injuries and MASD. Findings: a. A review of Resident 1's Record of admission indicated the facility admitted the resident on 5/14/2015 and readmitted the resident on 5/11/2023, with diagnoses including chronic respiratory failure (is a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), diabetes type 2 (an impairment in the way the body regulates and uses sugar [glucose] as a fuel), and end stage renal disease (when the kidneys can no longer support the body's needs). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/19/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required extensive assistance on bed mobility; and total assistance on dressing, eating, toilet use, and personal hygiene. The resident required two person-assist. The MDS also indicated the resident was always incontinent of urine and stools (feces). The MDS further indicated the resident was at risk for developing pressure injuries and was on pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention, application of nonsurgical dressings, and application od ointments/medications. A review of Resident 1's Assessment of Decubitus Ulcer Potential (an assessment tool to measure damage to the area on the skin caused by constant pressure), dated 5/12/2023, indicated that the resident was at risk to develop decubitus ulcers. A review of Resident 1's Resident Care Plan, last re-evaluation done on 5/15/2023, indicated a care plan of alteration in skin integrity related to presence of left and right buttock MASD, right inner thigh MASD, sacrococcyx (large, triangle-shaped bone in the lower spine that forms part of the pelvis which is fused with the coccyx) MASD, and left and right posterior MASD. The care plan indicated an intervention to turn and reposition every (q) 2 hours. A review of Resident 2's Physician Orders, dated 6/13/2023, indicated an order on 6/13/2023 for: - MASD wound on the left buttock, cleanse with (w/) normal saline (NS, mixture of salt and water as a cleaning solution) pat dry, apply ammonium lactate lotion (to treat dry or scaly skin and inherited dry skin condition), then Aquaphor (healing ointments, designed to heal minor cuts and cracked skin) to periwound (the skin around the wound). Cover w/ dry gauze and foam dressing. -MASD wound of left posterior thigh, cleanse w/ NS, pat dry, apply calcium alginate (used in the fabrication of wound dressing) to open wounds. Apply ammonium lactate lotion, then Aquaphor to peri wound. Cover w/ dry gauze and foam dressing. -MASD wound of right buttock, cleanse w/ NS, pat dry. Apply calcium alginate to open wounds. Apply ammonium lactate lotion, then Aquaphor to peri wound. Cover w/ dry gauze and foam dressing. -MASD wound of right posterior thigh, cleanse w/ NS, pat dry. Apply calcium alginate to open wounds. Apply ammonium lactate solution, then Aquaphor to peri wound. Cover w/ dry gauze and foam dressing. -MASD wound of sacrum, cleanse w/ NS, pat dry. Apply calcium alginate to open wounds. Apply ammonium lactate lotion, then Aquaphor to peri wound. Cover w/ dry gauze and foam dressing. Start 6/13/2023 daily (qd) and as needed (PRN) for soilage and dislodgement for 30 days (until 7/12/2023). On 5/11/2023, check low air loss mattress (LALM) pressure every shift set at LALM setting per resident weight in pounds (lbs) for skin management A review of Resident 1's Wound Care Progress Notes, dated 7/10/2023, indicated that for wound management, use low air loss mattress set according to patient's weight, provide adequate nutrition and hydration. A review of Resident 1's Specialty Physician Wound Evaluation & Management Summary, dated 7/10/2023, indicated a recommendation to off-load wound and reposition per facility protocol. During a concurrent observation and interview on 7/10/2023, at 9:56 a.m., with Licensed Vocational Nurse (LVN 1), observed the LALM was set to 9 and it should be 6-7 for resident weight of 110-130 pounds. LVN 1 was not aware of how long the setting was on 9. LVN 1 stated that he does not know why it was max inflated. LVN 1 stated that the bed should not be max inflated, it should be based on the patient's weight in pounds. LVN 1 stated that the resident's weight was 119.7 pounds. LVN 1 stated the LALM was too hard for the resident. LVN 1 stated that the deficient practice had the potential to cause worsening of the skin injury of the resident in the buttocks. During an interview on 7/10/2023, at 10 a.m., the Dialysis Nurse (DN) stated the resident should be turned every 2 hours since the resident had a skin injury. The DN stated that it was the staff nurse's responsibility to turn the resident. During an interview on 7/10/2023, at 11:32 a.m., the Treatment Nurse (TN) stated the bed should be set at 6, and that the setting at 9 would not be good for the resident's skin. The TN stated the deficient practice can lead to further skin breakdown. During an interview on 7/12/2023, at 8:50 a.m., the Director of Staff Development (DSD) stated she had in-serviced (educated) the staff regarding the use of the LALM. The DSD stated that the firmness of the mattress should be based on the weight of the resident. The DSD stated that the deficient practice can aggravate the pressure injury of the resident due to the mattress being max inflated. During an interview on 7/12/2023, at 9:53 a.m., the Director of Nursing (DON) stated the staff should have set the LALM according to resident's weight. The DON stated the failure to set the bed according to the resident's weight could result to aggravation of the skin condition of the resident. A review of In-Service Lesson Plan titled Follow Doctor's Order as Written, Medical Abbreviations, Low Air Loss Mattress, and Nurses Notes, dated 2/2/2023, indicated low air loss mattress must be placed at patient's weight, unless otherwise stated. A review of In-Service Lesson Plan titled Infection Control, Trach Care/Assessment, Low Air Loss Mattress/Repositioning & Turning. dated 2/28/2023, indicated a physician's orders will be obtained for the use of a low air loss mattress. The proper setting of the low air loss mattress will be confirmed based on the resident's care plan. The weight setting of the low air loss mattress will be included in the Medication Administration Record (MAR) under the treatments. A review of the undated SKINGUARD (brand of LALM) Mattress Series Owner's Manual, indicated under Patient Setup, to set the patient's height and weight, and press the PATIENT SETUP button. In this menu, use the ADJUST SETTINGS arrows to enter the patient's weight and height. Use the SELECT button to accept the weight and height values. Once set, the mattress will inflate to the recommended comfort pressure level and should be adjusted to patient's desired comfort level. b. A review of Resident 1's Certified Nursing Assistant (CNA) Documentation, dated 7/1/2023 to 7/11/2023 indicated that on: 7/1/2023 at 4 p.m. to 6 a.m. of 7/2/2023, the resident was on semi-Fowler's (is lying on the back with the head and torso raised between 15 and 45 degrees) and back position. 7/2/2023 at 7 a.m. to 10 p.m., the resident was on semi-Fowlers and back position. From 11 p.m. of 7/2/2023 to 7 a.m. of 7/3/2023, there was no documented turning. 7/3/2023 at 7 a.m. to 7 a.m. of 7/4/2023, the resident was on back and semi-Fowler's position. 7/4/2023 at 8 a.m. to 7 a.m. of 7/5/2023, the resident was on back and semi-Fowler's position. 7/5/2023 at 8 a.m. to 7 a.m. of 7/6/2023, the resident was on back and semi-Fowler's position. 7/6/2023 at 8 a.m. to 2 p.m., the resident was on back and semi-Fowler's position. From 4 p.m. to 11 p.m., there was no documented turning. From 12 midnight of 7/7/2023 to 6 a.m., the resident was on back position. 7/7/2023 at 8 a.m. to 7 a.m. of 7/8/2023, the resident was on semi-Fowlers and back position. 7/8/2023 at 8 a.m. to 12 p.m., the resident was on semi-Fowlers and back position. From 1 p.m. to 7 a.m. of 7/9/2023, there was no documentation of turning. 7/9/2023 at 7 a.m. to 7 a.m. of 7/10/2023, there was no documented turning. During an interview on 7/10/2023, at 9:56 a.m., Licensed Vocational Nurse 1 (LVN 1) stated the resident was last turned at 7:30 a.m. LVN 1 stated the resident needed to be turned every 2 hours to prevent further skin injury to resident. During an interview on 7/10/2023, at 10 a.m. the DN stated the resident should be turned every 2 hours since she has skin injury. The DN stated that it was the staff nurse's responsibility to turn the resident and not them. During a concurrent interview and record review on 7/10/2023, at 2:59 p.m., with Nursing Supervisor 2 (NS 2), observed missing documentations of turning every 2 hours in the resident's chart from 7/1/2023 to 7/10/2023. NS 2 stated on 7/9/23, 7/8/2023, from 1 p.m. to 7 a.m. of 7/9/2023, 7/6/2023 from 3 p.m. to 11 p.m., 7/12/2023 from 11 p.m. to 7 a.m. of 7/13/2023 were left blank. NS 2 stated that in nursing if it is not documented, it was not done. NS 2 stated the deficient practice had to potential to worsen the skin injury of the resident. During an interview on 7/12/2023, at 8:50 a.m., the DSD stated the staff should have completed the documentation of turning every 2 hours to assure that the residents were being turned on a timely manner. The DSD stated in nursing, if it was not documented, it did not happen. The DSD further added that when you place a resident on a semi-Fowler's position, the pressure will be more on the coccyx, but the back still has pressure. During an interview on 7/12/2023, at 9:53 a.m., the DON stated the staff should turn the resident every 2 hours to prevent further skin breakdown. A review of the facility's recent policy and procedure titled Turning Schedule and Repositioning Guidelines, last reviewed on 1/26/2023, indicated that nursing will evaluate patients on admission and as required in determining individualized need for routine turning, and repositioning while in bed to prevent the development, deterioration, or decubitus ulcers and any other adverse effect to lying stationary. Patients who have been designated in need of routine positioning will be turned while in bed at least every 2 hours and as needed. Unless contraindicated the patient may be positioned on both sides and back to equalize the pressure over time. A review of the facility's recent policy and procedure titled Charting, last reviewed on 1/26/2023, indicated for licensed personnel, meaningful and informative progress notes are to be written as often as the resident's condition warrants. Progress notes are to reflect observations of the resident's response to his environment, physical limitations, independent activities, dependency status, behavioral changes, skin problems, dietary problems, and restorative measures to characterize the functional status of progression and/or regression. Narrative notes shall be made by nursing assistants whenever appropriate and only after such assistants have been properly instructed. They shall include: 1. Care and treatment done with and for the resident. 2. Residents' reactions to the care and treatment. 3. Daily observation of how the resident looks, feels, reacts, interacts, the degree of dependency and motivation towards improved health. A review of the facility's recent policy and procedure titled Pressure Sore Prevention and Management, last reviewed on 1/26/2023, indicated the purpose of the policy was to identify residents at high risk for developing pressure sores. Interventions include to turn every 2 hours while in bed.

Based on observation, interview, and record review, the facility failed to observe infection control measures for one of four sampled residents (Residents 1) by failing to: 1. Label the ventilator circuit tubing (used to deliver gas from a positive pressure ventilator [a device for maintaining artificial respiration] to the patient) to Resident 1. 2. Change the suction canister (a temporary storage container for secretions or fluids removed from the body) of Resident 1 dated 7/4/2023 on 7/6/2023 per facility protocol. The deficient practices placed the resident at increased risk for infections due to potential growth of bacteria and viruses on the respiratory tubing and collection device. Findings: A review of Resident 1's Record of admission indicated the facility admitted the resident on 5/14/2021 and readmitted the resident on 5/11/2023, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on respirator (a machine used to help a patient breathe), and diabetes type 2 (an impairment in the way the body regulates and uses sugar [glucose] as a fuel). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/19/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, tracheostomy care (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and invasive mechanical ventilator (a type of ventilation that involves the insertion of an artificial airway into the trachea [windpipe]). A review of Resident 2's Physician Orders, dated 5/11/2023 indicated to change closed suction catheter system every Monday and Thursday and if necessary (PRN) by respiratory therapist and to change vent circuit every month and PRN soiled or damp. During a concurrent observation and interview on 7/10/2023, at 12:09 p.m., with Nursing Supervisor 1 (NS 1), observed the tracheostomy vent circuit undated and the suction canister dated 7/4/2023 more than half full of greenish sections at the bedside. NS 1 stated the suction canisters are changed every Tuesdays and Thursdays. NS 1 stated that the suction canisters should have been changed on 7/6/2023. NS 1 stated the vent circuit tubing should be dated to know when it was replaced. NS 1 further stated the deficient practice had to potential to cause infection to residents. During an interview on 7/10/2023, at 2:39 p.m., the Infection Preventionist (IP) stated the vent tubing circuit should have been dated by the respiratory therapist (RT) to know when to change the vent circuit again. The IP also stated that the suction canister should have been changed on 7/6/2023 to prevent growth of bacteria and infection. During an interview on 7/12/2023, at 8:50 a.m., the Director of Staff Development (DSD) stated that if she found a vent circuit that was undated, she would change the vent circuit right away and date them. The DSD stated the deficient practice had a potential for infection and bacterial growth. The DSD also stated the staff should have changed the suction canister when it was half full as soon as possible because infection can set in. During an interview on 7/12/2023, at 9:53 a.m., the Director of Nursing (DON) stated the staff should have changed the vent circuit and suction canister per protocol to prevent infection. A review of the facility's recent policy and procedure titled Equipment Changing- Shift Responsibilities, last reviewed on 1/26/2023, indicated in order to adhere to the infection control guidelines, the Department of Respiratory Care will designate the following equipment changing responsibilities to the Respiratory Care Practitioners assigned to a particular shift and work area. Adult patients vent circuits are changed the first weekend of every month and PRN. A review of the facility's recent policy and procedure titled Suction Canister and Tubing Change, last reviewed on 1/26/2023, indicated the purpose of this policy is to provide a guideline for the routine and PRN change of suction canisters and their tubing. The suction canister will be changed every Tuesday and Friday by Housekeeping. The suction canisters will be labeled with the resident's name and the date the canister was changed. The suction canister tubing will be labeled with the date it was changed. The suction canister and tubing will be changed PRN when the suction canister is 500 or less.

Based on interview, and record review the facility failed to ensure transportation was provided to and from the ophthalmology services location for one out of four residents (Resident 1). This deficient practice resulted in the delay in providing ophthalmology services to Resident 1. Findings: A review of the Record of admission indicated the facility admitted Resident 1 on 11/21/2017 and readmitted the resident on 5/12/2023 with diagnoses including chronic respiratory failure (a serious condition that makes it difficult to breathe on your own), essential (primary) hypertension (a condition in which the blood vessels have persistently raised pressure), and dependent on respirator ([ventilator] using an apparatus designed to control air that is breathed through it to either intermittently or continuously assist or control pulmonary ventilation, without which, the patient would not be able to breathe independently). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 2/5/2023, indicated Resident 1 is totally dependent on bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Nursing Progress notes dated 8/3/2022 at 3:15 p.m. indicated an order received for an ophthalmology consult scheduled for 11/10/2022. A review of Nursing Progress notes dated 11/10/2022 at 2:55 p.m. indicated transportation service was late in picking up Resident 1 for ophthalmology consult, ophthalmology consult was cancelled and will be rescheduled by Transportation Coordinator (TC). A review of Nursing Progress notes dated 11/11/2022 at 9:08 a.m. indicated new order was received for an ophthalmology consult scheduled for 2/23/2023 at 2 p.m. A review of Nursing Progress notes dated 2/23/2023 at 2:30 p.m. indicated transportation service arrived two hours late, clinic was made aware, Resident 1 could not be seen today, a new appointment was scheduled for June 1, 2023. During an interview on 5/10/2023 at 5p.m. with the Director of Nursing (DON), the DON stated they are having issues with providing transportation for Resident 1 since the facility is required to use the resident ' s insurance to obtain transportation services. The DON stated the scheduled transportation services arrived late or did not have the right equipment to transport Resident 1 and facility had to reschedule the resident ' s appointment. During an interview on 5/24/2023 at 10:35 a.m. with the TC, the TC stated that in May 2022, Resident 1 received authorization to be seen by an eye doctor and based on the resident ' s diagnosis and condition, the doctor requested for the resident to be seen by a cornea specialist. The TC stated the resident missed his appointment on 11/10/2022 and 2/23/2023 due to issues with the transportation company. During an interview on 5/24/2023 at 9:35a.m. with the Administrator (Adm), the Adm stated Resident 1 ' s insurance only covers a specific transportation company to provide transportation services to the resident. The Adm stated they have made many complaints to the insurance company regarding the resident ' s missed appointment. During a follow-up interview on 5/24/2023 at 11:33 p.m. with the Adm, the Adm stated Resident 1 has yet to see the cornea specialist. The Adm stated they must work within the guidelines provided by insurance or must seek out to the family a private transportation, but family may not be able to pay for it. A review of facility ' s policy and procedures titled Physician Orders, last revised on 3/12/2023 indicated responsible for carrying out the physician ' s orders with proper documentation. A review of facility ' s policy and procedures titled Resident Appointments, Consultations and Follow-up Appointments, last revised on 7/2022 indicated resident appointment must be made timely and accurately by the Appointment Clerk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent formation and progression of a pressure injuries (an injury to skin and underlying tissue due to prolonged pressure over a bony structure) for two of three sampled residents (Residents 1 and 2) by: 1. Failing to adjust the low air loss mattress (LALM - a mattress used to provide airflow to help skin dry, as well as to relieve pressure) based on the patient's weight distribution for Resident 2 who had a stage 4 pressure injury (deep wound reaching the muscles, ligaments, or bones) at the coccyx (tailbone). 2. Failing to turn Resident 1 who had multiple pressure injuries stage 4 located on the left and right shoulder, left hip, and sacrum; stage 1 on left medial ankle; and deep tissue injury (DTI, an injury to the soft tissue under the skin due to pressure and is usually over bony prominence) on the left heel, right lateral ankle, and right heel; and failing to turn Resident 2 who had a stage 4 pressure injury at the coccyx every two hours to prevent worsening of pressure injuries. The deficient practices had the potential to cause worsening of the pressure injuries among the residents. Findings: a. A review of Resident 2's Record of admission indicated the facility admitted the resident on 10/20/2021 and readmitted the resident on 12/29/2022, with diagnoses including chronic respiratory failure (is a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on respirator (a machine used to help a patient breathe), and diabetes type 2 (an impairment in the way the body regulates and uses sugar [glucose] as a fuel). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/18/2022, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was totally dependent on bed mobility, dressing, eating, toilet use, and personal hygiene. The resident required one to two persons' assistance. The MDS also indicated the resident was always incontinent of stools (feces). The MDS further indicated the resident was at risk for developing pressure injuries and was on pressure reducing device for bed, turning/repositioning program, and nutrition or hydration intervention. A review of Resident 2's Assessment of Decubitus Ulcer Potential (an assessment tool to measure damage to the area on the skin caused by constant pressure), dated 1/5/2023, indicated that the resident was at risk to develop decubitus ulcers (pressure injuries). A review of Resident 2's Wound Care Progress Notes, dated 1/13/2023, indicated to use low air loss mattress set according to patient's weight, provide adequate nutrition and hydration, turn, and reposition every two hours with good body alignment for wound management. A review of Resident 2's Specialty Physician Wound Evaluation & Management Summary, dated 2/21/2023, indicated a recommendation to reposition per facility protocol, and off-load wound. A review of Resident 2's Physician Orders, dated 2/22/2023, indicated an order for sacrum pressure injury stage 4: Cleanse and irrigate wound with normal saline (mixture of salt and water), pack wound with gauze or kerlix soaked in quarter percent Dakin's (used to kill and prevent the growth of bacteria or germs in wounds), cover with dry gauze and foam dressing daily and if necessary (prn) for out/dislodged for 30 days (until 3-23-2023) and re-evaluate. A review of Resident 2's Treatment Record, dated 12/29/2022, indicated check low air loss mattress pressure every shift, set according to resident's weight in pounds (unit of measure) for skin management. The Treatment Record indicated resident's weight was 106 pounds on 2/24/2023. A review of Resident 2's Resident Care Plan, last re-evaluation done on 2/23/2023, indicated a care plan of alteration in skin integrity related to presence of sacrum pressure injury stage 4. The care plan indicated an intervention to turn and reposition every two hours, provide pressure relieving devices as indicated. During a concurrent observation and interview on 2/27/2023, at 9:35 a.m., with the Treatment Nurse (TN), observed the LALM was set at 400 or maximum inflation. The TN stated that she does not know why it was max inflated. The TN stated that the bed should not be max inflated, it should be based on the patient's weight in pounds. The TN sated that the resident's weight was 106 pounds and the LALM was too hard for the resident. The TN stated that the deficient practice had the potential to cause worsening of the pressure injury of the resident in the coccyx. During an interview on 2/27/2023, at 1:49 p.m., with the Director of Nursing (DON), the DON stated that the staff should have not left the LALM max inflated. The DON stated that the bed should be set according to resident's weight. The DON stated that the deficient practice had the potential to aggravate the pressure injury of the resident. During an interview on 2/27/2023, at 2:03 p.m., with the Director of Staff Development (DSD), the DSD stated that that she had in-serviced (trained) the staff regarding the use of the LALM. The DSD stated that the firmness of the mattress should be based on the weight of the resident. The DSD stated that the deficient practice can aggravate the pressure injury of the resident due to the mattress being max inflated. A review of the manufacturer's recommendation for SUPRA CXC (Low Air Loss Alternating Pressure Mattress Replacement System, undated, indicated that users can adjust pressure of air mattress to a desired softness by adjusting the pressure knob. Please consult your physician for a suitable setting. b.1. A review of Resident 1's Record of admission indicated the facility admitted the resident on 6/8/2022 and readmitted the resident on 12/26/2022, with diagnoses including chronic respiratory failure, dependence on respirator, and pressure ulcer (pressure injury) of left hip stage 4. A review of Resident 1's MDS, dated [DATE], indicated the resident was totally dependent on bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident was at risk for developing pressure injuries. The MDS indicated the resident was on a pressure reducing device for bed, on turning/repositioning program, and on nutrition and hydration intervention to manage skin problems. A review of Resident 1's Nurses' admission Record, dated 1/12/2023, indicated that the resident had multiple pressure injures stage 4 located on the left and right shoulder, left hip, and sacrum; stage 1 on left medial ankle; and DTI on the left heel, right lateral ankle, and right heel. A review of Resident 1's Assessment of Decubitus Ulcer Potential, dated 12/28/2022, indicated that the resident was at risk to develop decubitus ulcers. A review of Resident 1's Specialty Physician Wound Evaluation & Management Summary, dated 1/17/2023, indicated to off-load wound and reposition per facility protocol. A review of Resident 1's Resident Care Plan, last re-evaluated on 1/26/2023, indicated a care plan of alteration in skin integrity related to multiple pressure injuries. The care plan indicated an intervention to turn and reposition every two hours, position resident in good body alignment, and provide pressure relieving device as indicated. A review of Resident 1's Wound Care Progress Notes, dated 12/27/2022, indicated an intervention to turn and reposition every two hours with good body alignment. A review of Resident 1's Certified Nursing Assistant (CNA) Documentation, dated 1/18/2023 to 1/19/2023, indicated resident turning position as follows: - On 1/1/2023 from 12 p.m. to 7 p.m. - resident was on his back. - On 1/18/2023 from 8 a.m. to 12 noon – resident was on his back - On 1/18/2023 from 2 p.m. to 6 p.m. - resident was on his back - On 1/18/2023 from 10 p.m. to 2 a.m. of 1/19/2023- resident was on the left side[ASL1] [RD2] [RD3] . b.2. A review of Resident 2's CNA Documentation, dated 2/19/2023 to 2/25/2023 indicated the following: - On 2/19/2023 from 10 a.m. to 5 p.m. – the resident was on semi-Fowlers position (the resident on their back with the head of the bed angled (elevated) 30 to 45 degrees) - On 2/19/2023 from 6 p.m. to 9 p.m. - resident was on his back - On 2/20/2023 from 2 a.m. to 6 a.m. - resident was on his back - On 2/25/2023 from 2 a.m. to 6 a.m. - resident was on his back - On 2/26/2023 from 2 a.m. to 6 a.m. - resident was on his back. During an observation and interview on 2/27/2023, at 9:54 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that she came in the facility to start her duty at 7 a.m. CNA 1 further stated that she has not seen and given care to Resident 2 until 9:54 a.m. CNA 1 stated that she was aware that the resident had pressure injury at the coccyx stage 4. CNA 1 added that to help prevent pressure injury, the resident should be turned every two hours. CNA 1 stated that she was not able to turn the resident at least every two hours because she got busy with another resident. CNA 1 stated that the deficient practice had the potential to worsen the pressure injury of Resident 2. During an interview on 2/27/2023, at 9:54 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that that they just repositioned Resident 2. CNA 2 stated they try to at least turn residents every two hours. CNA 2 stated that both she and CNA 1 had 50 residents that was why they were not able to turn the resident on time. CNA 2 also stated that she started at 7 a.m. and just had the time to turn Resident 2 at 9:54 a.m. CNA 2 stated that the failure to turn the resident every two hours can potentially worsen the pressure injury of Resident 2. During an interview on 2/27/2023, at 10:32 a.m., with the TN, the TN stated that the residents with pressure injuries should be turned every two hours to prevent worsening of pressure injuries. During an interview on 2/27/2023, at 1:49 p.m., with the DON, the DON stated that the staff should document the position changes every two hours and not repeating same position in a span of four hours or more. The DON stated that if the resident refuses to turn, it should be care planned, resident should be educated on the risk and should be documented on the care plan. A review of the facility's recent policy and procedure titled Turning Schedule and Repositioning Guidelines, revised on 12/2016, indicated that nursing will evaluate patients on admission and as required in determining individualized need for routine turning, and repositioning while in bed to prevent the development, deterioration, or decubitus ulcers and any other adverse effect to lying stationary. Patients who have been designated in need of routine positioning will be turned while in bed at least every 2 hours and as needed. Unless contraindicated the patient may be positioned on both sides and back to equalize the pressure over time.

Based on observation, interview, and record review, the facility failed to observe infection control measures for 1 of 3 sampled residents (Residents 2) by failing to wear gown, gloves, and face shield before entering Resident 2's room who was on isolation for carbapenem-resistant enterobacterales (CRE, are strains of bacteria that are resistant to an antibiotic class [carbapenem] used to treat infections). The deficient practice placed the residents at increased risk for infections due to cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) and spread of among the residents. Findings: A review of Resident 2' Record of admission indicated the facility admitted the resident on 10/20/2021 and readmitted the resident on 12/29/2022, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on respirator (a machine used to help a patient breathe), and diabetes type 2 (an impairment in the way the body regulates and uses sugar [glucose] as a fuel). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/18/2022, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was totally dependent on bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 2's Physician Orders, dated 12/29/2022, indicated an order to place resident on contact isolation (potential exposure through touch) due to multidrug-resistant organisms (MDRO, microorganisms predominantly bacteria, that are resistant to one or more classes of antimicrobial agents) and CRE. During an observation and interview on 2/27/2023, at 9:26 a.m., with Central Supply Staff (CSS), observed CSS going inside Resident 2's room while not wearing a face shield, gown, and gloves to stock the gloves inside the room. Resident 2 was less than six feet distance to the glove rack. CSS stated that he should have worn a face shield, gown, and gloves prior to entering the room of the resident to prevent catching or giving infection to the resident. The TN was inside the room and stated that CSS should have worn complete personal protective equipment (PPE, specialized clothing or equipment worn by employee for protection against infectious materials, i.e., mask, face shield, gowns, and gloves) inside the room to prevent cross contamination of infection. During an interview on 2/27/2023, at 1:49 p.m., with the Director of Nursing DON), the DON stated that the CSS should have worn a mask, face shield, gowns, and gloves prior to entering the room of Resident 2. The DON stated that the deficient practice had the potential to cross contaminate infection. A review of the signage posted on the entrance door of Resident 2, undated, indicated a sign indicating contact isolation. The sign indicated enhanced standard precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms): (1) Handwashing; (2) Gloves; (3) Gown; (4) Mask, and (5) Goggles. A review of the facility's recent policy and procedure titled, Personal Protective Equipment (PPE), last reviewed on 2/2022, indicated that personal protective equipment is to be used as necessary for optimal protection of healthcare personnel. It is used to prevent contamination of clothing and skin. PPE includes items such as gloves, gowns, masks, respirators, eyewear used to create barriers that protect skin, clothing, mucous membranes, and the respiratory tract from infectious agents.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by not covering the end tip of gastrostomy tube (GT- a flexible tube surgically inserted through the abdominal wall into the stomach for the administration of food and medication) extension set to prevent cross contamination (the transfer of bacteria or other microorganisms from one person, object or place to another) for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at higher risk of infections. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 5/7/2020 with diagnoses including gastrostomy (the surgical formation of an opening through the abdominal wall into the stomach). A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 10/31/2022, indicated the resident was sometimes able to make understand others and required extensive assistance with transfer, dressing, and eating. A review of the physician ' s order for Resident 2, dated 9/9/2022, indicated to provide tube feeding formula at 150 milliliters (ml) three times a day to provide 450 ml (at 12 a.m., 4 a.m., and 8 p.m.). During a concurrent observation and interview, on 1/6/2023 at 11:50 a.m., Registered Nurse 1 (RN 1) verified Resident 2 ' s feeding formula left in a bag (about 500 ml) hanging on the pole (to hang the formula and feeding machine), there was no cap at the end tip of the GT extension line touching an object on the bedside table. There was no date labeled on the connected four-extension set to lengthen the line. RN 1 stated the GT extension end tip should be covered with a cap when not in use and the entire extension set was contaminated. RN 1 stated the licensed nurses should label with the date when changing the GT extension set. On 1/6/2023 at 4:05 p.m., during an interview, the Infection Preventionist (IP) stated, the nursing staff should label with the date for all feeding tubes including extension sets when they change, and they should cover the end tip of feeding tube with a cap to reduce a risk of cross contamination. On 1/6/2023 at 4:30 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated, did not notice that the end tip was not covered and touching to the objects at bed side, the end tip of tube feeding should be stored in a clean bag not to be contaminated when not in use, otherwise microorganisms could go into the feeding tube through the opened end tip, and the feeding formula could be contaminated. A review of the facility ' s policy and procedures, revised 9/2022, titled, Infection Control Plan indicated, The Infection Control Program has established the policies and procedures for the investigation, control, and prevention of transmission of disease and infections within the facility. The following apply: Monitor staff performance to ensure policies and procedures for preventing the spread and occurrence of infection are properly executed. A review of the facility ' s policy and procedures, dated March 2022, titled, GT Feeding Tube Care indicated, The purpose of this policy is to provide a guideline for the care of feeding back lines when not in use. Resident feeding back lines will be secured and covered with end caps or a clean plastic bag when not in use to prevent contamination. A review of the facility ' s policy and procedures, dated February 2022, titled, GT Extension Set Use indicated, A GT extension set will be attached to a GT to facilitate feeding and medication administration, lengthening of GT feeding line, and venting the GT as needed The GT extension set will be changed every Monday and prn (as needed) by a licensed nurse. The GT extension set will be labeled with the date of when it was changed.

Based on interview and record review, the facility failed to ensure the resident ' s responsible party (RP) had the right to be informed of a new treatment on the right foot due to a fungal infection (skin infection) for one of six sample residents (Resident 1). On 6/23/2022, the attending physician ordered topical (on the skin) treatments to Resident 1 ' s right toes to treat a fungal infection. RP was not informed of the new infection and treatment. This deficient practice resulted in a violation of RP ' s right to be informed and participate in the care of Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 12/07/2021 and readmitted him on 06/04/2022, with diagnoses including chronic respiratory failure (a condition in which your blood doesn't have enough oxygen) and tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe]). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) dated 06/16/2022 indicated the resident ' s cognition for daily decision making was intact and independent (problems with a person's ability to think, learn, remember, use judgement, and make decisions), and needed extensive assistance for activities of daily living assistance. A review of Physician ' s Orders for Resident 1 dated 06/23/2022 indicated to provide treatments for a fungal infection of the right toes with an antifungal cream daily for 30 days. On 10/14/2022, at 2 p.m., during an interview with Registered Nurse 1 (RN 1) and concurrent review of Resident 1 ' s progress notes and physician ' s orders, RN 1 stated she informed RP but could not find evidence of it in the clinical record. RN 1 stated she failed to document the RP notification. A review of the facility ' s reviewed 01/01/2020 policy and procedures titled, Reporting Changes in Condition indicated To ensure the appropriate and timely notification of changes in condition to a resident ' s family/responsible party and physician The nursing staff will report significant changes in a resident ' s condition or status to the resident ' s family/responsible party in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident ' s call devices were within reach for two of six sampled residents (Resident 4 and 5), and to responding to call lights in a timely manner for two of six sampled residents (Resident 2 and 3). This deficient practice placed the resident at risk of inability to summon health care workers as needed to receive the assistance. Findings: A review of admission Record indicated the facility admitted Resident 4 on 03/26/2015 and readmitted on [DATE], with diagnoses including chronic respiratory failure (a condition in which your blood doesn't have enough oxygen) and tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe]). A review of Resident 4 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) dated 08/17/2022 indicated the resident ' s cognition for daily decision making was severely impaired (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) and needed total care. During a concurrent observation and interview, on 10/14/2022, at 11:45 a.m., CNA 1 found Resident 4 ' s call light on the nightstand that was not within reach. The CNA 1 stated that the call light was within reach just a while ago, and anyway this resident was unable to use the call light so that staff have to check the resident ' s needs. A review of admission Record indicated the facility admitted Resident 5 on 02/24/2021, with diagnoses including respiratory failure and tracheostomy. A review of Resident 5 ' s MDS dated [DATE] indicated the resident ' s cognition for daily decision making was severely impaired and needed total care. During a concurrent observation and interview, on 10/14/2022, at 11:50 a.m., CNA 1 found Resident 5 ' s call touch pad on the nightstand that was not within reach. The CNA 1 stated that even the resident was not able to use the call touch pad, the staff should check the call touch pad placement and leave it within reach all the times. A review of admission Record indicated the facility admitted Resident 2 on 04/14/2016 and readmitted on [DATE], with diagnoses including chronic respiratory failure and tracheostomy. A review of Resident 2 ' s MDS dated [DATE] indicated the resident ' s cognition for daily decision making was independent, and the resident understood others and was understood by others. The MDS also indicated, the resident needed extensive assistance by two persons physical assist for transfer and needed total care for toilet use. During an interview, on 10/14/2022, at 12:02 p.m., Resident 2 stated, she had to wait longer than two hours especially at night, seemed like that it happened every one or two months, the staff were doing better for a couple of months after having a meeting to solve her concerns, but it happened again. Resident 2 stated that she was incontinent (an unintentional passing of urine or bowel movement) and wore the briefs underwear, so that she needed to be changed promptly when she was soiled. Resident 2 stated, recently it happened one night of last week and she had to wait for about two hours to be cleaned. A review of admission Record indicated the facility admitted Resident 3 on 05/14/2015 and readmitted on [DATE], with diagnoses including chronic respiratory failure and tracheostomy. A review of Resident 3 ' s MDS dated [DATE] indicated the resident ' s cognition for daily decision making was independent, and the resident understood others and was understood by others. The MDS also indicated, the resident needed extensive assistance by two persons physical assist for bed mobility and needed total care for toilet use and personal hygiene. During an interview, on 10/14/2022, at 12:27 p.m., Resident 3 stated, she had to wait for about 30 minutes very often when she used her call light, there was no specific time of the day, they don ' t come right away most of time, and she had to wait for their response at least 30 minutes almost every time. During an interview, on 10/14/2022, at 3:09 p.m., the Director of Staff Development (DSD) stated, the facility staff always should check the call devices ' placements within reach for all residents even the resident does not have the ability to use them, and the call lights should be answered immediately, or the staff should inform the resident how soon they will provide the service unless the resident needs urgent care. A review of the facility ' s revised 11/2014 policy and procedure titled CALL LIGHTS indicated To enable patients/residents to call for assistance and to enable all staff to respond to call lights in a timely and efficient manner The call light will be placed within reach Call lights will be answered timely and efficiently. Call lights should be answered immediately, by any staff member. Call lights will be monitored for positioning by Licensed Nurses and Certified Nursing Assistants during rounds and after treatments.

Based on observation, interview, and record review the facility failed to initiate a baseline care plan (a plan created immediately upon admission to properly care for the resident to reduce the likelihood of a negative outcome) for one out of one sampled resident (Resident 85) on the use of an anticoagulant (blood thinner medication). The deficient practice had the potential to cause adverse (unfavorable) side effects to Resident 85. Findings: A review of Resident 85's Face Sheet indicated the facility admitted the resident, on 6/3/2022, with diagnoses that included tracheostomy (an opening surgically created through the neck into the windpipe that provides an alternative airway for breathing) and gastrostomy (surgical procedure used to insert a tube through the abdomen and into the stomach), anemia (a condition that occurs when your blood has lower than normal amount of red blood cells), and intracranial injury (violent blow or jolt to the head or body). A review of Resident 85's History and Physical (H&P), dated 6/4/2022, indicated the resident did not have the capacity to understand and make decisions. Resident 85 had traumatic brain injury (TBI- happens when a sudden external, physical assault damages the brain) and status post craniotomy (any surgical incision into the skull). A review of Resident 85's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/14/2022, indicated the resident could make self-understood and had no ability to understand others. Resident 85 had severely impaired cognitive skills (gaining of knowledge and understanding) for daily decision making. The MDS indicated Resident 85 was on an anticoagulant. A review of Resident 85's physician orders, dated 6/6/2022, indicated an order for Lovenox (anticoagulant medication) 40 mg (milligrams -unit of measurement) sq (subcutaneously - applied under skin) once daily for deep vein thrombosis prophylaxis (pharmacologic measures to diminish the risk of forming blood clots in the deep veins) until further notice. During an interview, on 10/24/2022 at 3:07 p.m., the Licensed Vocational Nurse 2 (LVN 2) stated Resident 85 did not have any care plan for at risk for bleeding secondary to Lovenox sq use. During an interview, on 10/27/2022 at 4:29 p.m., the Director of Nursing (DON) and Director of Staff Development (DSD) both stated they should have created a care plan for anticoagulant (Lovenox sq) use to monitor for side effects such as bleeding and bruising. During an interview, on 10/28/2022 at 8:29 a.m., the Pediatric Nurse Manager (PNM) stated they should have created a care plan for anticoagulant use to monitor the side effects of the medication such as bleeding. A review of the facility's policy and procedure titled Baseline Care Plans, reviewed 7/28/2022, indicated the Interdisciplinary Team (a group of healthcare providers from different fields who work together toward the same goal to provide the best care or best outcome for a resident or group of residents) shall develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 85's Face Sheet indicated the facility admitted the resident, on 6/3/2022, with diagnoses including tracheostomy (an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube) and gastrostomy (surgical procedure used to insert a tube through the abdomen and into the stomach), anemia (happens when a person doesn't have the normal amount of red blood cells), and intracranial injury (a violent blow or jolt to the head or body). A review of Resident 85's History and Physical (H&P), dated 6/4/2022, indicated the resident did not have the capacity to understand and make decisions. Resident 85 had traumatic brain injury (TBI- cause by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth) and status post craniotomy (the surgical removal of part of the bone from the skull to expose the brain). A review of Resident 85's MDS, dated [DATE], indicated the resident could not make self-understood and had no ability to understand others. Resident 85 had severely impaired cognitive (gaining of knowledge and understanding) skills for daily decision making. The MDS indicated Resident 85 was on an anticoagulant medication. A review of Resident 85's physician orders, dated 6/6/2022, indicated an order for Lovenox 40 milligrams (mg- a measure of weight) subcutaneously once daily for deep vein thrombosis prophylaxis (pharmacologic measures to diminish the risk of blood clots forming in the deep vein) until further notice. During an interview, on 10/24/2022 at 3:07 p.m., the Licensed Vocational Nurse 2 (LVN 2) stated Resident 85 did not have any care plan for at risk for bleeding secondary to Lovenox use. During an interview, on 10/27/2022 at 4:29 p.m., with Director of Nursing (DON) and Director of Staff Development (DSD), they both stated they should have created a care plan for anticoagulant (Lovenox) use to monitor for side effects of anticoagulant use such as bleeding, bruising etc. During an interview, on 10/28/2022 at 8:29 a.m., Pediatric Nurse Manager (PNM) stated they should have created a care plan for anticoagulant use to monitor the side effects of the medication such as bleeding. A review of the facility's policy and procedure titled Comprehensive Care Plans, reviewed 7/28/2022, indicated that the comprehensive care plans will be reviewed, revised, and completed within seven days after completion of the comprehensive assessment, which is prepared by the interdisciplinary team, that includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a member of food and nutrition services staff, the resident and/or representative to the extent possible, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Based on observation, interview, and record review, the facility failed to develop and create a care plan (help residents work with their care team to plan, document, and accomplish individualized care goals and healthier outcomes) by: a. Failing to ensure Resident 248 had a care plan addressing the use of intravenous fluid infusion (IVF infusion - a medical technique that administers fluids, medications or nutrients directly into a person's vein) as ordered by the physician. This deficient practice may lead to a delay in or lack of delivery of care and services. b. Failure to create a comprehensive care plan for one out of two sampled residents (Resident 85) on the use of anticoagulant (Lovenox- a medication that helps prevent the formation of blood clots) administered subcutaneously (sq- applied under the skin). This deficient practice had the potential for adverse (unfavorable) side effects of the medication to Resident 85. Findings: a. A review of Resident 248's Face Sheet indicated the facility originally admitted the resident, on 8/12/2022 and readmitted on [DATE], with the diagnoses that included chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), tracheostomy(a surgically created hole {stoma} on the windpipe [trachea] that provides an alternative airway for breathing), gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube), and intracranial abscess (a collection of pus that develops in the brain due to an infection). A review of Resident 248's History and Physical, dated 9/26/2022, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 248's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 10/5/2022, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident needed total assistance from staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident received 51% or more their total calories through tube feeding. During an observation, on 10/24/2022 at 12:15 p.m., Resident 248 was lying in bed, awake, with intravenous fluid (IVF - specially formulated liquids that are injected into a vein to prevent or treat dehydration). A review of Resident 248's Intravenous Therapy Record indicated the resident had been receiving IVF infusion of D5 ½ NS (dextrose and normal saline -type of fluid for hydration) 1 liter at 70 cubic centimeters (cc - a unit of volume for liquids) since 10/23/2022 per hour. A review of Resident 248's physician orders indicated an order for D5 ½ NS 1 Liter at 70 cc per hour via PICC line (peripheral inserted catheter - a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart generally used to give medications or liquid nutrition), dated 10/23/2022, at 5:45 p.m. During a concurrent record review and interview, on 10/27/2022 at 11 a.m., the Minimum Data Set Nurse 1 (MDSN 1) stated there was no care plan developed for the IVF infusion and there should have been a short-term care plan. MDSN 1 stated care plan development with measurable goals were important to communicate the reason for the infusion and to evaluate the outcome timely. MDSN 1 stated it could delay and lack the necessary care and services for the resident. During an interview, on 10/27/2022 at 11:30 a.m., the Director of Nursing (DON) stated there should have been a care plan for the IVF infusion. The DON stated the care plan was important to prevent delay in providing the necessary care and services needed by the resident. A review of the facility's policy and procedure titled, Long Term and Short-Term Care Plans, last reviewed on 7/28/2022, indicated, care plans will be updated and revised dependent on the progress, change in condition, or as new diagnosis arises and are identified. The policy also indicated short-term care plans will be re-evaluated if the goals are not met within the target date. A review of the facility's policy and procedure titled, Comprehensive Care Plans, last reviewed on 7/28/2022, indicated a policy statement to develop and implement a person-centered care plan for each resident, consistent with the resident rights, and includes measurable objective and time frame to meet a resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to evaluate and revise the care plan for one of one sampled resident (Resident 37) who was at risk for potential infection related to jejunostomy tube (JT- surgery to create an opening into the small intestine from the outside of the body) opening or stoma (an artificial created hole in the abdomen that brings nutrition directly to the stomach). This deficient practice has the potential to cause infection to the stoma without revision of the plan of care. Findings: A review of Resident 37's Face Sheet indicated the facility admitted the resident, on 11/30/2014 and readmitted on [DATE], with diagnoses that included chronic respiratory failure (when not enough oxygen passes from your lungs to your blood), tracheostomy (an opening surgically created through the neck into the wind pipe), and gastrointestinal dysmotility (a disorder where muscles of the digestive system become impaired leading to changes in the speed, strength, or coordination). A review of Resident 37's History and Physical (H&P), dated 8/11/2022, indicated the resident's neurological status was intact. A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/5/2022, indicated the resident could make self-understood and understand others. Resident had intact cognition (gaining of knowledge and understanding). The MDS indicated the resident had total dependence on eating. A review of Resident 37's physician orders, indicated the resident was to receive: - jejunostomy tube feeding of Peptamen [NAME] (a nutritionally complete, easy to digest and easy to absorb formula) at 65 milliliters (ml- a metric unit of volume) per hour via pump for 20 hours to provide 1300 ml/1300 kilo calorie (kcals- is a standard of unit which is used to measure the energy content of foods and beverages) every 24 hours (off 0800 on at 1200), dated 4/08/2022. A review of Resident 37's Care Plan, dated 2/8/2022, indicated a presence of JT. The care plan indicated the resident was at risk for potential or actual infection related to aspiration and/or jejunostomy tube opening or stoma. The care plan's interventions were to prevent infection, check positioning of tubing, and to assess the JT site for redness drainage, and signs and symptoms of infection or irritation before administration of any care to resident. The care plan's interventions include to secure all tubing properly with no traction prior to repositioning and turning resident and assess resident after care was rendered. During an observation, on 10/24/2022 at 8:35 a.m., Resident 37's tube feeding lines were on the floor. Resident 37 stated the staff did not educate her regarding the risk of keeping her feeding tubing on the floor. During an interview, on 10/24/2022 at 2:57 p.m., the Assistant Pediatric Nurse Manager (APNM) stated he educated Resident 37 regarding keeping tubing off the floor to prevent infection. The APNM was not able to find any documentation of a revision of the care plan to reflect education explaining the risk of keeping the tubing on the floor to Resident 37. During an interview, on 10/27/2022 at 4:29 p.m., Director of Nursing (DON) and Director of Staff Development (DSD) both stated the staff should have documented the education regarding non-compliance to keeping the tubing off the floor of Resident 37 in the care plan. The DON and DSD stated the care plan helped the staff individualize the care they provide to each resident. During an interview, on 10/28/2022 at 8:29 a.m., the Pediatric Nurse Manager (PNM) stated education should have been documented in the care plan if the resident was non-compliant with the care being provided. The PNM stated the care plan was important because it served as the basis of care for each resident. A review of the facility's policy and procedure titled Comprehensive Care Plans, review date of 7/28/2022, indicated that care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality by failing to ensure the peripherally inserted center catheter (PICC - a long, flexible catheter [thin tube] inserted into a vein in the upper arm used to administer medication) dressing (a sterile protectant covering over the PICC insertion site) was labeled with the date and time, for one of one sampled residents (Resident 296). This deficient practice had the potential to result in delay in care and treatment and increased risk of infection. Findings: A review of Resident 296's Face Sheet indicated the facility admitted the resident on 5/23/2022 and readmitted on [DATE] with diagnoses that included chronic respiratory failure (a condition where not enough oxygen passes from the lungs into the blood) and persistent vegetative state (a condition in which a patient is completely unresponsive to psychological and physical stimuli). A review of the Resident 296's History and Physical, dated 10/12/2022, indicated Resident 296 did not have the capacity to understand and make decisions. A review of Resident 296's Minimum Data Set (MDS- an assessment and care screening tool) dated 8/4/2022 indicated Resident 296 was totally dependent on staff for mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 296's physician's orders, indicated the resident was to receive: -Left upper arm PICC line, triple lumen (three smaller tubes); flushing, caring, dressing change per facility protocol by Registered Nurse on duty, dated 10/12/2022. A review of Resident 296's Care Plan titled, Resident has PICC line, left upper arm, initiated 10/13/2022, indicated the line would be free from complications at all times and to change the dressing per protocol and as needed. During an observation, on 10/24/2022 at 2 p.m., Resident 296 was lying in bed with a transparent film dressing placed over a left upper arm PICC line. The dressing was observed not labeled. Resident 296 was non-interviewable. During an observation and interview, on 10/24/2022 at 2:15 p.m., Licensed Vocational Nurse (LVN 6) assessed Resident 296's PICC line dressing and stated there was no label on the dressing to indicate the date the dressing was last changed. LVN 6 stated the Registered Nurses changed the dressing and there should be a date on it. During an observation and interview, on 10/24/2022 at 2:21 p.m., Registered Nurse 2 (RN 2) stated the Registered Nurse cleaned and changed the PICC line dressing once a week on the night shift. RN 2 stated staff labeled dressings with a date to communicate, by looking at the dressing, when it (PICC line was cleaned, and dressing changed) was last done. RN 2 assessed Resident 296's PICC line dressing and stated there was no date on the dressing but there should be. RN 2 stated it was important to know the date when the dressing was last changed because it should be changed weekly to reduce the risk of infection. RN 2 stated she would change the resident's dressing and date it because she could not be sure when it was last changed. During an observation, on 10/27/2022 at 10:10 a.m., Resident 296 was lying in bed with a transparent film dressing placed over the PICC line. Resident 296's dressing was observed not labeled. During an observation and interview, on 10/27/2022 at 10:12 a.m., RN 3 assessed Resident 296 and stated the PICC line dressing was not dated but it should be. During an interview, on 10/27/2022 at 12:23 p.m., the Director of Nursing (DON) stated PICC line dressings should be labeled with a date per facility policy. The DON stated the importance of labeling the dressing with a date was to know the last time the dressing was changed and to ensure the assessment of the insertion site and for signs and symptoms of infection. A review of the facility's policy and procedures titled, Central Venous Catheters (CVC): Care and Maintenance, last reviewed 7/28/2022, indicated the purpose of the policy and procedure was to provide guidelines for the care and maintenance of all types of central venous catheters including dressing and site care. Procedures related to CVCs must be performed by a registered nurse. CVC sterile dressing change is done once a week and as needed. The policy further indicated to apply a transparent dressing to protect the exit site and date and initial the dressing on the tape.

Based on observation, interview, and record review, the facility failed to properly treat residents' contractures (muscles or tendons that have remained too tight for too long, thus becoming shorter) for two of two sampled residents (Resident 49 and Resident 66) by failing to follow physician orders to: 1. Apply bilateral hand rolls for Resident 49. 2. Apply hand rolls for Resident 66. This deficient practice had the potential to further affect the resident's limited range of motion and further worsening of their contractures. Findings: a. A review of Resident 49's Record of admission indicated the facility admitted the resident on 9/20/2011, and most recently readmitted the resident on 7/5/2022, with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), encounter for attention to tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and dependence on ventilator (machine that helps patients breathe when they cannot breathe on their own). A review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2022, indicated the resident's cognitive skills (mental skills used in acquiring knowledge, processing information, reasoning, and problem-solving) for daily decision making is severely impaired. The MDS further indicated Resident 49 was totally dependent on staff for activities of daily living (ADL-activities related to personal care that includes bed mobility, transfers, dressing, toilet use, and personal hygiene) and has functional limitation in range of motion with impairment on both sides of upper and lower extremities. A review of Resident 49's physician's order Physician Orders, indicated an order dated 7/5/2022, to use bilateral hand rolls at all times every (q) shift. A review of Resident 49's care plan, last updated on 8/11/2022, indicated a goal that the resident will be prevented from decline or minimize decline in the range of motion daily until the next review in three months and included an intervention to apply bilateral hand rolls at all times. During an observation, on 10/25/2022 at 9:51 a.m., observed Resident 49 lying in bed and noted with contractures to bilateral upper and lower extremities. Observed resident without hand rolls in both hands. During a concurrent observation and interview, on 10/25/2022 at 10:27 a.m., Registered Nurse 1 (RN 1) observed and verified Resident 49 did not have hand rolls in either hands. RN 1 reviewed Resident 49's physician orders and confirmed there is an order to use bilateral hand rolls at all times. RN 1 stated the hand rolls should have been applied to each hand following the physician's order to prevent the contractures in both hands from worsening. RN 1 checked Resident 49's bedside and closet and stated he could not find any hand rolls belonging to the resident. During an interview, on 10/28/2022 at 9:24 a.m., the Restorative Nursing Assistant 3 (RNA 3) stated she is the assigned RNA for Resident 49 and confirmed that the resident should have hand rolls to both hands at all times. RNA 3 stated the hand rolls prevent the resident from closing their fingers in and keep the hands more open to prevent the contractures from becoming worse. During an interview, on 10/28/2022 at 2:30 p.m., the Director of Nursing (DON) reviewed Resident 49's physician's order and confirmed bilateral hand rolls should have been applied at all times following the physician's order. The DON stated it is important to ensure hand rolls are applied to residents with upper extremity contractures in order to maintain alignment of the hands and fingers and prevent further contractures. A review of the facility's policy and procedure titled, Hand Splints and Rolls, last reviewed on 7/28/2022, indicated hand splints and rolls are used for positioning and prevention of contractures. The policy and procedure further indicated patients identified as needing hand rolls will receive order from the physician and once the order is received, the order will be noted and carried out. b. A review of Resident 66's Record of admission indicated the facility admitted the resident on 4/19/2013, with diagnoses including encounter for attention to tracheostomy (a tube inserted through a cut in the neck below the vocal cords to allow air to enter the lungs), encounter for attention to gastrostomy (G-tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach), and gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus [the tube that carries food from your throat into stomach]). A review of Resident 66's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/1/2022, indicated the resident usually made self-understood and had the ability to understand others. The MDS also indicated Resident 66 was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene and had impairment in functional limitation in range of motion on both sides of upper and lower extremities. A review of Resident 66's Physician Orders indicated an order dated 10/29/2016, to apply both hand rolls at all times. A review of Resident 66's Care Plan for limitations in the functional range of motion dated 7/2021, indicated an intervention to apply both hand rolls. During an observation on 10/28/2022 at 9:05 a.m., observed Resident 66 not having hand rolls on. During a concurrent observation and interview on 10/28/2022 at 10:50 a.m., with Restorative Nurse Assistant 4 (RNA 4), RNA 4 verified Resident 66 did not have hand rolls on. RNA 4 checked the resident's drawer and did not find the hand rolls. RNA 4 stated it is important to have hand rolls on to prevent further contractures. RNA 4 stated the resident should have the hand rolls on at all times. During an interview on 10/28/2022 at 2:25 p.m., with the Director of Nursing (DON), the DON stated hand rolls are used to prevent further contractures. The DON stated Resident 66 should have had her hand rolls on. A review of the facility's policy and procedure titled, Hand Splints and Rolls, last reviewed on 7/28/2022, indicated, Hand splints and or hand rolls are used for positioning and for prevention of contractures .Patients identified as needing hand rolls will receive order from Physician .Once order has been received from Physician the order will be noted and carried out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two out of eight residents (Residents 79 and 85) were free from unnecessary drugs by: 1. Failing to monitor for the side effects of anticoagulant (blood thinner) use such as bruising and bleeding on Resident 85. 2. Failing to clarify the order of Lovenox (a drug that helps prevent the formation of blood clots) subcutaneous (sq- beneath, or under, all the layers of the skin) indicating until further notice use, no stop date on Resident 85. 3. Failing to clarify an order for Metronidazole (antibiotic - medication used to treat bacterial infections) which was indicated for loose stools and did not have a stop date on Resident 79. These deficient practices had the potential to cause adverse (unfavorable) side effects to residents due to prolonged use. Findings: a. A review of Resident 85's Record of Admission, indicated that the facility admitted the resident on 6/3/2022, with diagnoses including tracheostomy (is an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube), gastrostomy (is a surgical procedure used to insert a tube through the abdomen and into the stomach), anemia (happens when a person doesn't have the normal amount of red blood cells), and intracranial injury (a violent blow or jolt to the head or body). A review of Resident 85's History and Physical (H&P), dated 6/4/2022, indicated that the resident does not have the capacity to understand and make decisions. The H&P indicated the resident had traumatic brain injury (TBI- happens when a sudden external, physical assault damages the brain) and status post craniotomy (any surgical incision into the skull). A review of Resident 85's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/14/2022, indicated that the resident cannot make self-understood and has no ability to understand others. The MDS indicated the resident had severely impaired cognitive skills (gaining of knowledge and understanding) for daily decision making. The MDS further indicated the resident was on anticoagulant. A review of Resident 85's Physician Orders, dated 6/6/2022, indicated an order for Lovenox 40 milligrams (mg-unit of measurement) subcutaneous (sq-under the skin) once daily for deep vein thrombosis prophylaxis (DVT PPX- pharmacologic measures to diminish the risk of forming blood clots in the deep veins) until further notice. During an interview on 10/27/2022, at 4:29 p.m., with Director of Nursing (DON) and Director of Staff Development (DSD), both stated that the facility should have monitored the side effects of the anticoagulant use such as bleeding on Resident 85. During an interview on 10/28/2022, at 8:29 a.m., with Pediatric Nurse Manager (PNM), the PNM stated that the staff should have monitored for the side effects of the anticoagulant use on Resident 85. The PNM stated it is important to monitor the side effects of the anticoagulant such as bleeding for patient safety. A review of the facility's recent policy and procedure titled Monitoring of Anticoagulation Therapy, reviewed date of 10/26/2022, indicated that the policy is used to monitor blood levels of patients receiving anticoagulant therapy. Patient's receiving Anticoagulation Therapy should be assessed for bruising, swelling, and/or redness every (Q) shift and if necessary (PRN). Medical Doctor (MD) should be notified immediately. b. A review of Resident 85's Record of Admission, indicated that the facility admitted the resident on 6/3/2022, with diagnoses including tracheostomy, gastrostomy, anemia, and intracranial injury. A review of Resident 85's H&P, dated 6/4/2022, indicated that the resident does not have the capacity to understand and make decisions. Resident 85 had TBI and status post craniotomy. A review of Resident 85's MDS, dated [DATE], indicated that the resident cannot make self-understood and has no ability to understand others. The MDS indicated the resident had severely impaired cognitive skills (gaining of knowledge and understanding) for daily decision making. The MDS further indicated the resident was on anticoagulant. A review of Resident 85's Physician Orders, dated 6/6/2022, indicated an order for Lovenox 40 mg sq once daily for DVT PPX until further notice. During an interview on 10/27/2022, at 4:29 p.m., with DON and DSD, both stated that the facility should have clarified the order of the anticoagulant (Lovenox sq) for Resident 85, as it does not have a stop date. During an interview on 10/28/2022, at 8:29 a.m., with PNM, the PNM stated that the staff should have called the doctor to clarify the anticoagulant (Lovenox sq) medication of Resident 85 and asked for a stop date. During an interview on 10/28/2022, at 1:23 p.m., with Pharmacist (Pharm), the Pharm stated that she only found out that there was an anticoagulant order for Resident 85 on 10/24/2022. She stated that she reviewed the anticoagulant (Lovenox sq) and she would make a recommendation to the primary physician of the resident to have a stop date for the medication. A review of the facility's recent policy and procedure titled Medication Orders for Anticoagulant Therapy, revised date of 7/28/2022, indicated that medications for Lovenox will have a length of time for reevaluation by the prescribing MD. c. A review of Resident 79's Record of admission indicated the facility admitted the resident on 3/9/2017, with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), dependence on ventilator (machine that helps patients breathe when they cannot breathe on their own), and hypoxic ischemic encephalopathy (brain dysfunction caused by lack of blood flow and oxygen to the brain). A review of Resident 79's History and Physical Progress Note, dated 11/1/2021, indicated resident has a history of ethylmalonic encephalopathy (inherited early onset progressive disorder affecting the brain, gastrointestinal tract, and blood vessels). A review of Resident 79's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/12/2022, indicated the resident's cognitive skills for daily decision making is severely impaired. The MDS further indicated Resident 79 was totally dependent on staff for activities of daily living (ADL - activities related to personal care) that includes bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 79's physician's order, ordered on 4/19/2017, indicated an order for Metronidazole (antibiotic used for treatment of bacterial infections) 187 milligrams (mg-unit of measurement) via gastrostomy tube (g-tube, feeding tube placed through the abdomen into the stomach to provide nutrition and medication) every eight hours (q8h) for loose stool. A review of Resident 79's Medication Record from April 2017 indicated Metronidazole 187 mg was administered via g-tube q8h from 4/19/2017 to 4/30/2017. A review of Resident 79's Medication Record from July 2020 indicated Metronidazole 187 mg was administered via g-tube q8h from 7/1/2020 to 7/31/2020. A review of Resident 79's Medication Record from October 2022 indicated Metronidazole 187 mg was administered via g-tube q8h from 10/1/2022 to 10/28/2022. During an interview, on 10/31/2022 at 8:08 a.m., the Consultant Pharmacist (Pharm) stated antibiotic use should be monitored for the right indication, dosing, length of therapy and for any possible interactions with other drugs. The Pharm verified Resident 79's physician order for Metronidazole 187 mg via g-tube indicated for loose stools with a start date of 4/19/2017. The Pharm stated the order does not have a duration indicating the length of therapy and confirmed antibiotic orders should have a duration and a stop date to justify its use. The Pharm explained the duration for Metronidazole normally ranges anywhere from five to 14 days depending on what is being treated. The Pharm also confirmed loose stools is not an adequate indication for why the antibiotic should be given and stated the order should have been clarified with the physician. The Pharm stated long term antibiotic use can potentially result in changes in the gut flora and can lead to antibiotic resistance. The Pharm further stated the importance of monitoring and reassessing antibiotic use to prevent the emergence of multidrug resistant organism (MDRO - organisms that are resistant to multiple antibiotics) from unnecessary antibiotic use. During an interview, on 10/31/2022 at 8:58 a.m., the Director of Nursing (DON) stated the physician's order for antibiotics should include the diagnosis or infection to indicate the reason for why it is being given. The DON confirmed loose stool indicated in Resident 79's Metronidazole order is not an adequate indication. The DON stated antibiotic orders should also include a duration specifying a stop date. The DON stated the licensed nurses should have identified Resident 79's order for Metronidazole did not have a stop date and notified the physician to decide if the antibiotic is still needed and should be continued or discontinued. The DON further stated it was missed and overlooked by everyone including the licensed nurses, physician, infection preventionist (IP), and the pharmacist. The DON stated the IP and the IP assistant audits the chart at least once per week to identify residents on antibiotics and to monitor for the right indication, dose, duration, drug interactions and effectiveness of the antibiotic. The DON stated the importance of ensuring that the right antibiotic with a stop date is administered to residents for a specific infection or diagnosis to prevent side effects and life-threatening adverse reactions and to prevent the residents from developing antibiotic resistance from long term antibiotic use which can lead to MDRO. During an interview, on 10/31/2022 at 9:25 a.m., Medical Doctor 1 (MD 1) stated the rationale for ordering Metronidazole for Resident 79 was specifically for the treatment for the resident's diagnosis of ethylmalonic encephalopathy. A review of the facility's policy and procedure titled, Antibiotic Therapy, last reviewed on 7/28/2022, indicated the physician's order for antibiotics must include the following: the name, dose, frequency, duration, and the reason for the antibiotic.

Based on interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for one of six sampled residents (Resident 13) by failing to: 1. Monitor and document specific target behaviors related to the use of clozapine (medication used to treat schizophrenia [a serious mental disorder in which people interpret reality abnormally]). 2. Monitor and document the side effects for sertraline (medication used to manage and treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest]). These deficient practices had the potential to result in unnecessary medications and can lead to adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) such as falls with injury and decline in quality of life for Resident 13. Findings: A review of Resident 13's Record of admission indicated the facility admitted the resident on 4/29/2020, and most recently readmitted the resident on 3/23/2022, with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), schizophrenia, and restlessness and agitation. A review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/3/2022, indicated the resident had the ability to make self usually understood and had the ability to usually understand others. The MDS further indicated Resident 13 was totally dependent on staff for activities of daily living (ADL - activities related to personal care) that included bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 13's physician's order, ordered on 9/9/2022, indicated an order for clozapine 100 milligrams (mg-unit of measure) tablet take 300 mg via gastrostomy tube (g-tube, feeding tube placed through the abdomen into the stomach for delivery of nutrients and medications) daily (QD) related to schizophrenia manifested by agitation/shouting for three months until 12/9/2022. A review of Resident 13's physician's order, ordered on 8/9/2022, indicated an order for sertraline 50 mg take one tablet via g-tube QD for depression manifested by sadness for six months until 2/10/2023. During a concurrent interview and record review, on 10/27/2022 at 10:24 a.m., Registered Nurse 6 (RN 6) stated licensed nurses monitor for behaviors and side effects for residents on psychotropic (medication capable of affecting the mind, emotions, and behavior) medications and document on the Medication Administration Record (MAR) every shift as hashmarks. RN 6 reviewed Resident 13's physician's orders and verified that the resident is on sertraline for depression and clozapine for schizophrenia. RN 6 stated Resident 13 has behaviors of agitation and shouting that staff should be monitoring for. RN 6 then reviewed Resident 13's MAR for October 2022 and verified the targeted behavioral monitoring of shouting and agitation related to clozapine use was not being monitored and documented on the MAR. RN 6 further stated the targeted behaviors of shouting and agitation should be monitored and documented on the MAR to allow the physician to review the behavioral episodes and decide if they will need to increase or decrease the dosage based on the number of episodes or discontinue the medication if the resident no longer needs it. RN 6 also verified Resident 13's physician's order to monitor side effects every shift using hashmarks for episodes related to Sertraline use. RN 6 reviewed Resident 13's MAR and confirmed there was no documented evidence of side effect monitoring for sertraline. RN 6 stated Resident 13 should have been monitored for side effects following the physician's order and documented on the MAR. RN 6 further stated the importance of monitoring side effects related to psychotropic medication use to prevent harm to the resident by intervening promptly if the resident has any adverse reactions and to evaluate if it is the right drug for the resident. During an interview, on 10/27/2022 at 2:20 p.m., the Director of Nursing (DON) stated residents on psychotropic and antipsychotic (medication used to manage abnormal condition of the mind described as involving a loss of contact with reality) medications should be monitored for behavioral episodes and confirmed the behavioral monitoring for Resident 13 related to shouting and agitation should have been documented in the MAR. The DON explained that hashmarks are documented in the MAR to indicate the number of behavioral episodes and a log is maintained for tallying the total number of behaviors for the entire month. The DON explained the licensed nurses would notify the attending physician if targeted behaviors increase and that the physicians also review the monitored behaviors documented on the MAR and log. The DON stated the admitting nurse should have called the physician and requested for an order for behavioral monitoring for clozapine. The DON stated if the behavioral monitoring did not appear on the MAR, staff will not monitor and document the behaviors. The DON further stated the staff must monitor for side effects related to psychotropic drug use and document on the MAR as well. The DON stated the importance of monitoring behaviors to assess if the medication is effective and for the physician to review the behavioral episodes to continue or adjust the medication accordingly. The DON further stated side effects related to sertraline use should be monitored and documented on the MAR for patient safety and to notify physician of any adverse side effects. The DON confirmed there is potential for residents to continue to receive unnecessary medications if behaviors and side effects are not monitored. A review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed on 7/28/2022, indicated behavior monitoring shall be initiated along with monitoring for possible side effects. The policy and procedure further indicated monitoring will be completed on the Medication Administration Record by appointed nursing staff such as tallying behaviors and adverse effects observed each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** g. A review of Resident 38's admission Record indicated the facility admitted the resident on 12/5/2016 and readmitted the resident on 7/2/2021, with diagnoses including chronic respiratory failure (a condition where not enough oxygen passes from the lungs into the blood) and gastrostomy tube (g-tube, a surgical procedure for inserting a tube through the stomach for feeding or drainage). A review of Resident 38's History and Physical dated 8/3/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS- an assessment and care screening tool) dated 2/8/2022 indicated Resident 38 was totally dependent on staff for mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident received 51% or more their total calories through tube feeding. A review of Resident 38's Physician Orders, indicated feeding orders for the following: 1. Gastrostomy tube feeding: Fibersource HN (a nutritionally complete tube feeding formula) at 50 cubic centimeters (cc, a unit of measurement) per hour for 22 hours, via pump (a mechanical device used to administer enteral feedings over an extended time) to provide 1100 cc/1320 Kilocalories (Kcals, a unit of calorie [a unit of energy] measurement) every 24 hours, dated 8/10/2022. 2.Change spike set (tubing, with a piercing spike to puncture an enteral feeding bag, used to administer enteral feedings) in each bag hung, dated 7/2/2021. A review of Resident 38's Care Plan (CP) titled, Presence of GT, dated 7/8/2022, indicated the resident was at risk for intolerance to artificial nutrition. The CP indicated the resident would remain free from signs or symptoms of malnutrition/dehydration and signs and symptoms of feeding intolerance. The CP further indicated to observe the resident for signs and symptoms of feeding intolerance (nausea, vomiting, diarrhea). During an observation on 10/24/22 at 9:45 A.M., observed Resident 38 lying in bed with the enteral feeding pump running Fibersource HN at 50cc per hour. The enteral feeding bag was labeled with the resident's name and rate of administration. Observed the spike tubing was not labeled. During a concurrent observation and interview on 10/24/2022 at 9:55 A.M., observed Licensed Vocational Nurse 4 (LVN 4) assess Resident 38's enteral feeding bag and spike tubing. LVN 4 stated the bag label was missing the date and time, and the tubing was not labeled. LVN 4 stated the bag and tubing were probably hung (started administering) during the night, but he could not be sure because the bag was not labeled with the date and time. LVN 4 stated the tubing and bag are changed every 24 hours when a new bag is hung. LVN 4 stated the proper process for hanging a new enteral feeding bag was to label the bag and tubing with the resident's name, and the date and time it was started. LVN 4 stated the importance of labeling was to know when the bag and tubing were started. During an observation on 10/27/22 at 8:54 A.M., observed Resident 38 lay in bed with the enteral feeding pump running Fibersource HN. The enteral feeding bag label did not have the time and the spike tubing was not labeled. During an interview on 10/27/2022 at 3:45 P.M. with the Director of Nursing (DON) and the Director of Staff Development (DSD), the DON stated every time a new bag (enteral feeding bag) is hung, the bag should be labeled with the resident's name, room number, date, and time. The DON reviewed the facility policy and procedure and stated the feeding bags and tubing are to be changed every 24 hours. The DON stated it is important to not use expired bags and tubing because it could cause gastrointestinal disturbances. The DSD stated enteral formula could spoil (go bad) after a certain amount of time. A review of the policy and procedures titled, Enteral Feeding-General Policy, last reviewed 7/28/2022, indicated enteral nutrition is provided for those residents who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. Unopened formula can be stores at room temperature unless recommended by manufacturer. Formula in a closed system may hang up to 24 hours or per manufacturer's recommendation. Label formula with time, date, resident's name and nurse's initials who hung. Administration bag and/or tubing shall be labeled with date and time and nurse's initials when changed. Administration bag and tubing should be changed daily for open systems. A review of the policy and procedures titled, Administration of Enteral Formulas via Pump, last reviewed 7/28/2022, indicated for a closed enteral feeding system to label the spike set with the date and nurse's initials. h. A review of Resident 61's admission Record indicated the facility admitted the resident on 6/9/2017 and readmitted the resident on 1/11/2018 with diagnoses including traumatic brain injury and gastrostomy tube (g-tube, a surgical procedure for inserting a tube through the stomach for feeding or drainage). A review of Resident 61's History and Physical dated 8/21/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 61's MDS dated [DATE] indicated Resident 61 was totally dependent on staff for mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident received 51% or more their total calories from through tube feeding. A review of Resident 61's Physician Orders, indicated feeding orders dated 8/21/2022 for the following: 1. Gastrostomy Tube Feeding: Fibersource HN (a nutritionally complete tube feeding formula) at 230 cubic centimeters (cc, a unit of measurement) per hour via pump (a mechanical device used to administer enteral feedings over an extended time) every 4 hours to provide 1380 cc/1656 Kilocalories (Kcals, a unit of calorie [a unit of energy] measurement) every 24 hours, dated 8/21/2021. 2. Change spike set (tubing with a piercing spike to puncture an enteral feeding bag) in each bag hung, dated 8/21/2021. A review of Resident 61's Care Plan (CP) titled, Presence of GT, dated 8/12/2022, indicated the resident was at risk for intolerance to artificial nutrition. The CP indicated the resident would remain free from signs or symptoms of malnutrition/dehydration and signs and symptoms of feeding intolerance. The CP further indicated to observe the resident for signs and symptoms of feeding intolerance (nausea, vomiting, diarrhea). During an observation on 10/24/22 at 9:50 A.M., observed Resident 61 lying in bed with the enteral feeding pump running Fibersource HN. The enteral feeding bag was labeled with the resident's name and rate of administration, the date and time were not indicated. During a concurrent observation and interview on 10/24/2022 at 9:55 A.M., observed Licensed Vocational Nurse 4 (LVN 4) assess Resident 61's enteral feeding bag and stated the bag label was missing the date and time and the tubing was not labeled. LVN 4 stated the bag and tubing were probably hung (started administering) during the night, but he could not be sure because they were not labeled with the date and time. LVN 4 stated the tubing and bag are changed every 24 hours when a new bag is hung. LVN 4 stated the proper process for hanging a new enteral feeding bag was to label the bag and tubing with the resident's name, and the date and time it was started. LVN 4 stated the importance of labeling was to know when the bag and tubing were started. During an observation on 10/27/22 at 8:55 A.M., Resident 61 lay in bed with the enteral feeding pump running Fibersource HN. The spike tubing was not labeled with the date. During an interview on 10/27/2022 at 3:45 P.M. with the Director of Nursing (DON) and the Director of Staff Development (DSD), the DON stated every time a new bag (enteral feeding bag) is hung, the bag should be labeled with the resident's name, room number, date, and time. The DON reviewed the facility policy and procedure and stated the feeding bags and tubing are to be changed every 24 hours. The DON stated it is important to not use expired bags and tubing because it could cause gastrointestinal disturbances. The DSD stated enteral formula could spoil (go bad) after a certain amount of time. During an observation on 10/28/22 at 8:52 A.M., observed Resident 61 lying in bed with the enteral feeding pump running Fibersource HN. The spike tubing was not labeled with the date. A review of the policy and procedures titled, Enteral Feeding-General Policy, last reviewed on 7/28/2022, indicated enteral nutrition is provided for those residents who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. Unopened formula can be stores at room temperature unless recommended by manufacturer. Formula in a closed system may hang up to 24 hours or per manufacturer's recommendation. Label formula with time, date, resident's name and nurse's initials who hung. Administration bag and/or tubing shall be labeled with date and time and nurse's initials when changed. Administration bag and tubing should be changed daily for open systems. A review of the policy and procedures titled, Administration of Enteral Formulas via Pump, last reviewed 7/28/2022, indicated for a closed enteral feeding system to label the spike set with the date and nurse's initials. d. A review of Resident 22's Record of admission indicated the facility admitted the resident on 1/7/2022, with diagnoses including dependence on respirator (a machine that helps a patient breathe when having surgery or cannot breathe on their own due to a critical illness), tracheostomy(a surgically created hole {stoma} on the windpipe [trachea] that provides an alternative airway for breathing) was changed, gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review if Resident 22's History and Physical dated 1/7/2022, indicated the resident had the assay (analyze or examine a situation) to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/18/2022, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident was totally dependent on staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated the resident received 51 percent (%) or more their total calories from through tube feeding. A review of Resident 22's Physician Orders, indicated an order dated 10/5/2022, for the Gastrostomy tube feeding: Fibersource HN (a nutritionally complete tube feeding formula) at 70 cubic centimeters (cc, a unit of measurement) per hour for 22 hours, via pump (a mechanical device use to administer enteral feedings over an extended time) to provide 1540 cc/1848 Kilocalories (Kcals, a unit of calorie [a unit of energy] measurement) every 24 hours for wound management. A review of Resident 22's Care Plan (CP) titled, Presence of GT, dated 1/10/2022, indicated the resident was at risk for intolerance to artificial nutrition. The CP's goal indicated the resident would remain free from signs or symptoms of malnutrition/dehydration and signs and symptoms of feeding intolerance. The CP further indicated to observe the resident for signs and symptoms of feeding intolerance (nausea, vomiting, diarrhea). During an observation on 10/24/22 at 12:00 P.M., observed Resident 22 lying in bed with the enteral feeding pump running Fibersource HN at 70 cc per hour. The enteral feeding bag was labeled with the resident's name, rate of administration, and date started. During a concurrent observation and interview on 10/24/2022 at 12:00 P.M., Licensed Vocational Nurse 7 (LVN 7) validated the feeding bag did not have a label that indicated the time it was changed. LVN 7 stated she was not sure the bag was changed during night shift because the label did not indicate the time it was changed. LVN 7 stated the feeding bag label should have indicated the time it was changed because the bag is only good for 24 hours. During follow-up observations on 10/25/22 at 8:15 a.m., 10/26/2022 at 8:05 a.m., 10/27/2022 at 8:30 a.m., observed Resident 22 lying in bed with the enteral feeding pump running Fibersource HN. Observed the enteral feeding bag with a label that did not indicate the time the bag was changed. During a concurrent interview and record review on 10/27/2022 at 3:45 P.M., the Director of Nursing (DON) stated every time a new enteral feeding bag is hung, the bag should be labeled with the resident's name, room number, date, and time. The DON reviewed the facility policy and procedure and stated the feeding bags and tubing are to be changed every 24 hours. The DON stated it is important to not use expired bags and tubing because it could cause gastrointestinal disturbances. The Director of Staff Development (DSD) stated enteral formula could spoil (go bad) after a certain amount of time. A review of the policy and procedures titled, Enteral Feeding-General Policy, last reviewed 7/28/2022, indicated the following: 1. Enteral nutrition is provided for those residents who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. Unopened formula can be stored at room temperature unless recommended by manufacturer. 2. Formula in a closed system may hang up to 24 hours or per manufacturer's recommendation. Label formula with time, date, resident's name and nurse's initials who hung. 3. Administration bag and/or tubing shall be labeled with date and time and nurse's initials when changed. A review of the policy and procedures titled, Administration of Enteral Formulas via Pump, last reviewed 7/28/2022, indicated to label the formula with the patient's name, room, date, time, rate, and initial. e. A review of Resident 24's Record of admission indicated the facility admitted the resident on 7/8/2022, with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), tracheostomy(a surgically created hole {stoma} on the windpipe [trachea] that provides an alternative airway for breathing) was changed, gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 24's History and Physical dated 7/10/2022, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/18/2022, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make themselves understood. The MDS also indicated Resident 24 was totally dependent on staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident received 51% or more their total calories from through tube feeding. A review of Resident 24's Physician's Orders, indicated an order dated 8/4/2022 for gastrostomy tube feeding: Fibersource HN (a nutritionally complete tube feeding formula) at 50 cubic centimeters (cc, a unit of measurement) per hour for 22 hours, via pump (a mechanical device used to administer enteral feedings over an extended time) to provide 1100 cc/1320 Kilocalories (Kcals, a unit of calorie [a unit of energy] measurement) every 24 hours, dated 8/4/2022. A review of Resident 24's Care Plan (CP) titled, Presence of GT, revised on 8/4/2022, indicated the resident was at risk for intolerance to artificial nutrition. The CP's goal indicated the resident would remain free from signs or symptoms of malnutrition/dehydration and signs and symptoms of feeding intolerance. The CP further indicated to observe the resident for signs and symptoms of feeding intolerance (nausea, vomiting, diarrhea). During an observation on 10/24/22 at 12:00 P.M., Resident 24 was lying in bed with the enteral feeding pump running Fibersource HN at 70 cc per hour. The enteral feeding bag was labeled with the resident's name, rate of administration, and date started. During a concurrent observation and interview on 10/24/2022 at 12:00 P.M., Licensed Vocational Nurse 7 (LVN 7) validated the feeding bag did not have a label that indicated the time it was changed. LVN 7 stated she was not sure if the bag was changed during night shift because the label did not indicate the time it was changed. LVN 7 stated the feeding bag label should have indicated the time it was changed because the bag is only good for 24 hours. During a concurrent interview and record review on 10/27/2022 at 3:45 P.M., the Director of Nursing (DON) stated every time a new bag (enteral feeding bag) is hung, the bag should be labeled with the resident's name, room number, date, and time. The DON reviewed the facility policy and procedure and stated the feeding bag and tubing are to be changed every 24 hours. The DON stated it is important to not use expired bags and tubing because it could cause gastrointestinal disturbances. A review of the policy and procedures titled, Enteral Feeding-General Policy, last reviewed 7/28/2022, indicated the following: 1. Enteral nutrition is provided for those residents who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. Unopened formula can be stored at room temperature unless recommended by manufacturer. 2. Formula in a closed system may hang up to 24 hours or per manufacturer's recommendation. Label formula with time, date, resident's name and nurse's initials who hung. 3. Administration bag and/or tubing shall be labeled with date and time and nurse's initials when changed. A review of the policy and procedures titled, Administration of Enteral Formulas via Pump, last reviewed 7/28/2022, indicated to label the formula with the patient's name, room, date, time, rate, and initial. f. A review of Resident 83's Record of admission indicated the facility admitted the resident on 7/8/2022, with diagnoses including dependence on respirator (a machine that helps a patient breathe when having surgery or cannot breathe on their own due to a critical illness),tracheostomy(a surgically created hole {stoma} on the windpipe [trachea] that provides an alternative airway for breathing) was changed , gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 83's History and Physical dated 8/8/2022, indicated, the resident does not have the capacity to understand and make decisions. A review of Resident 83's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/18/2022, indicated the resident had a moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident received 51% or more their total calories from through tube feeding. A review of Resident 83's Physician's Orders, indicated an order dated 8/9/2022, for gastrostomy tube feeding: Fibersource HN (a nutritionally complete tube feeding formula) at 85 cubic centimeters (cc, a unit of measurement) per hour for 22 hours, via pump (a mechanical device used to administer enteral feedings over an extended time) to provide 1700 cc/2060 Kilocalories (Kcals, a unit of calorie [a unit of energy] measurement) every 24 hours. A review of Resident 83's Care Plan (CP) titled, Presence of GT, revised on 8/9/2022, indicated the resident was at risk for intolerance to artificial nutrition. The CP indicated the resident would remain free from signs or symptoms of malnutrition/dehydration and signs and symptoms of feeding intolerance. The CP further indicated to observe the resident for signs and symptoms of feeding intolerance (nausea, vomiting, diarrhea). During an observation on 10/24/2022 at 10:00 a.m., observed Resident 83 lying in bed with the enteral feeding pump running Fibersource HN at 85 cc per hour. The enteral feeding bag was labeled with the resident's name, rate of administration, and date started. During a concurrent observation and interview on 10/24/2022 at 10:00 a.m., Licensed Vocational Nurse 7 (LVN 7) validated the bag label was missing the time it was changed. LVN 7 stated she was not sure if the bag was changed during night shift because the label did not indicate the time it was changed. LVN 7 stated the feeding bag label should have indicated the time it was changed because the bag is only good for 24 hours. During a concurrent interview and record review on 10/27/2022 at 3:45 p.m., the Director of Nursing (DON) stated every time a new bag (enteral feeding bag) is hung, the bag should be labeled with the resident's name, room number, date, and time. The DON reviewed the facility policy and procedure and stated the feeding bag and tubing are to be changed every 24 hours. The DON stated it is important to not use expired bags and tubing because it could cause gastrointestinal disturbances. A review of the policy and procedures titled, Enteral Feeding-General Policy, last reviewed 7/28/2022, indicated the following: 1. Enteral nutrition is provided for those residents who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. Unopened formula can be stored at room temperature unless recommended by manufacturer. 2. Formula in a closed system may hang up to 24 hours or per manufacturer's recommendation. Label formula with time, date, resident's name and nurse's initials who hung. 3. Administration bag and/or tubing shall be labeled with date and time and nurse's initials when changed. A review of the policy and procedures titled, Administration of Enteral Formulas via Pump, last reviewed 7/28/2022, indicated to label the formula with the patient's name, room, date, time, rate, and initial. i. A review of Resident 79's Record of admission indicated the facility admitted the resident on 3/9/2017, with diagnoses including encounter for attention to gastrostomy (a surgical opening into the stomach from the abdominal wall), chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), and dependence on ventilator (machine that helps patients breathe when they cannot breathe on their own). A review of Resident 79's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/12/2022, indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS further indicated Resident 79 was totally dependent on staff for activities of daily living (ADL - activities related to personal care) that includes bed mobility, transfers, dressing, toilet use, and personal hygiene. During a concurrent observation and interview, on 10/24/2022 at 2:29 p.m., Registered Nurse 1 (RN 1) stated the irrigation bottle and the 60 milliliter (mL) syringe used for flushing the g-tube, administering medications, and checking residual are changed every 24 hours by the night shift licensed nurse. RN 1 stated he would know when it was last changed by looking at the labeled date on the irrigation bottle. RN 1 observed and verified there was no date labeled on Resident 79's irrigation bottle indicating the date it was changed. RN 1 stated he will replace with a new irrigation bottle and label with date since he does not know when it was last changed. RN 1 further stated the irrigation bottle and syringe need to be replaced daily due to potential contamination and for infection control. During an interview, on 10/27/2022 at 1:51 p.m., the Director of Nursing (DON) stated the irrigation bottle should be changed every 24 hours and as needed if it is dirty or accidentally dropped on the floor. The DON stated the irrigation bottle needs to be labeled with the date and time it was changed and the resident's name. The DON further stated the purpose of changing the irrigation bottle daily is for infection control purposes. A review of the facility's policy and procedure titled, Irrigation Bottles, last reviewed on 7/28/2022, indicated the irrigation bottles will be changed daily by the certified nursing assistant or primary nurse and that the irrigation bottles will be labeled with the patient's last name, date, and room/bed number. Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (a form of nutrition that is delivered into the digestive system as a liquid) for nine (Resident 25, 77, 66, 22, 24, 83, 38, 61, and 79) of 10 sampled resident investigated under the care area of tube feeding by failing to: 1. Ensure residents had their head of the bed elevated while receiving enteral feeding for three of 10 sampled residents (Resident 25, 77, and 66). This deficient practice had the potential to place the residents at risk for aspiration (accidentally inhaling an object or fluid into their windpipe and lungs). 2. Ensure the enteral feeding bags were labeled with the time they were started for three out of 10 sampled residents (Resident 22, 24, and 83). This deficient practice had the potential to place the residents at risk for complications of enteral feeding such as diarrhea or vomiting which may lead to dehydration. 3. Ensure the enteral feeding bag and tubing was appropriately labeled for two of 10 sampled residents (Resident 38 and 61). This deficient practice had the potential to place the residents at risk for complications of enteral feeding such as diarrhea or vomiting. 4. Ensure the irrigation bottle and syringe used for the gastrostomy tube (g-tube, a surgically placed device that passes through the abdominal wall into the stomach) was labeled with the date it was changed for one of 10 sampled residents (Resident 79). This deficient practice had the potential for contamination and placed the residents at risk for infection. Findings: a. A review of Resident 25's Record of admission indicated the facility originally admitted the resident on 5/2/2019 and readmitted the resident on 6/9/2019, with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), encounter for attention to tracheostomy (a tube inserted through a cut in the neck below the vocal cords to allow air to enter the lungs), and encounter for attention to gastrostomy (G-tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach). A review of Resident 25's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/19/2022, indicated the resident rarely/never made self-understood and rarely/never had the ability to understand others. The MDS also indicated Resident 25 was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene and had impairment in functional limitation in range of motion on both sides of upper and lower extremities. A review of Resident 25's physician's orders indicated an order dated 6/9/2019, to elevate head of bed 30-45 degrees during feeding (aspiration precaution). A review of Resident 25's care plan for presence of g-tube updated on 6/24/2022, indicated a goal that the resident will be free from any signs and symptoms of aspiration at all times and an intervention to elevate head of bed at least 30-45 degrees. During an observation on 10/24/2022 at 9:10 a.m., observed Resident 25 lying in bed receiving enteral feeding and with head of bed at 20 degrees as indicated by bed frame indicating head of bed degrees. During a concurrent observation and interview on 10/24/2022 at 9:22 a.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 verified Resident 25's head of the bed was at 20 degrees. LVN 5 stated the head of the bed should be between 30-45 degrees when receiving enteral feeding because there is a risk for aspiration. During an interview on 10/27/2022 at 3:52 p.m., with the Director of Staff Development (DSD), the DSD stated resident's head of the bed should be at least 30-45 degrees when receiving enteral feeding. The DSD stated it is important to have the head of the bed elevated to avoid aspiration. A review of the facility's policy and procedure titled, Administration of Enteral Formulas Via Pump, last reviewed on 7/28/2022, indicated, Elevate the head of the bed 30-45 degrees before starting the feeding and 30-60 minutes after the feeding has stopped. b. A review of Resident 77's Record of admission indicated the facility originally admitted the resident on 11/18/1997 and readmitted the resident on 10/10/2021, with diagnoses including chronic respiratory failure, encounter for attention to tracheostomy, and encounter for attention to gastrostomy. A review of Resident 77's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/20/2022, indicated the resident was in a persistent vegetative state/no discernible consciousness. The MDS also indicated Resident 77 was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene and had impairment in functional limitation in range of motion on both sides of upper and lower extremities. A review of Resident 77's Physician Orders indicated an order dated 10/24/2014, to elevate head of bed 30-45 degrees during feeding (aspiration precaution). A review of Resident 77's Care Plan for presence of g-tube updated on 10/24/2022, indicated a goal that the resident will be free from any signs and symptoms of aspiration at all times and an intervention to elevate head of bed at least 30-45 degrees. During a concurrent observation and interview on 10/24/2022 at 9:25 a.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 verified Resident 77's head of the bed was at 20 degrees. LVN 5 stated the head of the bed should be between 30-45 degrees when receiving enteral feeding because there is a risk for aspiration. During an interview on 10/27/2022 at 3:52 p.m., with the Director of Staff Development (DSD), the DSD stated resident's head of the bed should be at least 30-45 degrees when receiving enteral feeding. The DSD stated it is important to have the head of the bed elevated to avoid aspiration. A review of the facility's policy and procedure titled, Administration of Enteral Formulas Via Pump, last reviewed on 7/28/2022, indicated, Elevate the head of the bed 30-45 degrees before starting the feeding and 30-60 minutes after the feeding has stopped. c. A review of Resident 66's Record of admission indicated the facility admitted the resident on 4/19/2013, with diagnoses including encounter for attention to tracheostomy, encounter for attention to gastrostomy, and gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus [the tube that carries food from your throat into stomach]). A review of Resident 66's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/1/2022, indicated the resident usually made self-understood and had the ability to understand others.

Based on interview and record review, the facility failed to ensure effective pain management was done by failing to document the pain assessments for one of one sampled resident (Resident 30) investigated under the care area of pain management. This deficient practice had the potential to result in lack of detection of unrelieved pain. Findings: A review of Resident 30's Record of admission indicated the facility originally admitted the resident to the facility on 5/14/2015 and readmitted the resident on 7/20/2022, with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), encounter for attention to tracheostomy (a tube inserted through a cut in the neck below the vocal cords to allow air to enter the lungs), and heart failure (heart is not pumping as well as it should be). A review of Resident 30's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/5/2022 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 30's Physician's Orders indicated the following: 1. Percocet (medication that treats moderate to severe pain) 10-325mg (milligram- unit of measurement) 1/2 tab via g-tube (gastrostomy tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach) every four (4) hours PRN (as needed) for moderate pain, ordered on 9/16/2022. 2. Percocet 10-325mg 1 tab via g-tube every 4 hours PRN for severe pain, ordered on 9/16/2022. 3. Morphine (medication that treats moderate to severe pain) 2 mg via g-tube every 4 hours PRN for severe pain, ordered on 9/16/2022. A review of Resident 30's Care Plan for potential in alteration in comfort related to pain indicated an intervention to administer medication as ordered and evaluate effectiveness 30 minutes after. During a concurrent interview and record review on 10/27/2022 at 2:27 p.m., with Licensed Vocational Nurse 4 (LVN 4), Resident 30's Controlled Drug Record (CDR), Medication Administration Record (MAR), and PRN Pain Assessment Flow Sheet (PAFS) and Nurses Medication Notes were reviewed. LVN 4 verified the following: -One dose of Percocet 10-325mg 1 tab documented on the CDR for 10/2/2022 was not documented on the PAFS or the Nurses Medication Notes and pre and post pain assessment was not done. -One dose of Morphine 2mg documented on the CDR for 10/10/2022 was not documented on the PAFS or the Nurses Medication Notes and pre and post pain assessment was not done. -One dose of Morphine 2mg documented on the CDR for 10/12/2022 was not documented on the PAFS or the Nurses Medication Notes and pre and post pain assessment was not done. -One dose of Morphine 2mg documented on the CDR for 10/16/2022 was not documented on the PAFS or the Nurses Medication Notes and pre and post pain assessment was not done. LVN 4 stated the procedure when giving controlled pain medications is to assess for pain and resident's pain scale. LVN 4 stated nonpharmacological interventions are done first and try to make the resident comfortable. LVN 4 stated if that does not work, give medication according to pain scale. LVN 4 stated to reassess the resident after 30 minutes of giving medication and document on the nurse's medication notes or pain assessment flowsheet and document the effectiveness of the medication and the time it was effective. During an interview on 10/27/2022 at 4:39 p.m., with the Director of Staff Development (DSD) and the Director of Nursing (DON), the DON stated licensed nurse is to assess resident for pain and try nonpharmacological interventions first before giving medication such as repositioning, checking if the resident is dirty, or if they need to defecate. The DON stated the licensed nurse is to check the effectiveness of the medication after an hour and notify the physician if it is not effective. The DON stated pain assessments should be documented. The DSD stated the pain assessment flowsheet is used to ensure nursing interventions are being done. The DSD stated documentation is important so that the licensed nurses can follow up to see if there is a pattern and to ensure the medication is effective. A review of the facility's policy and procedure titled, Pain Management, last reviewed on 7/28/2022, indicated, Nurse will document the level of pain in the nurses notes/flow sheet .When medications and/or comfort measures, if applicable, are taken the nurse will then follow up with the patient to ensure that the patient is free of pain and comfortable. The nurse will then document their findings in the nurses notes/flowsheets .If the medication is ineffective the physician will be contacted immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 11's Record of admission indicated the facility admitted the resident on 3/31/2014 and readmitted the resident on 7/17/2017 with diagnoses that included chronic respiratory failure (a condition where not enough oxygen passes from the lungs into the blood) and thyrotoxicosis (a condition in which there is too much thyroid hormone in the body). A review of Resident 11's History and Physical dated 8/16/2022, indicated the resident had the capacity to understand and make decisions. A review of Resident 11's Minimum Data Set (MDS- an assessment and care screening tool) dated 1/22/2022 indicated Resident 61 the resident had the ability to understand others and had to ability to make self-understood. A review of Resident 11's Care Plan (CP) titled, Potential for Sensory/Perceptual deficit related to glaucoma (a disease that damages the optic [eye] nerve), initiated 7/18/2022, indicated to administer eye medication as ordered. A review of Resident 11's Physician Orders, indicated ocular (eye) medication orders for the following: - Brimonidine (Alphagan, a medication used to treat glaucoma) 0.2%, ophthalmic (eye) one drop, instill 1 drop in both eyes, three times a day for glaucoma, dated 7/17/2017. -Durzolamine (Trusopt, a medication used to treat glaucoma), ophthalmic one drop in left eye, three times a day, dated 8/21/2021. -Space eye medications five minutes apart. During a Medication Pass Observation on 10/26/2022 at 12:03 p.m., with Licensed Vocational Nurse 10 (LVN 10) at Medication Cart 9, LVN 10 assisted Resident 11 in administering the Alphagan and Trusopt eye drops. The Alphagan was administered in both eyes, immediately followed by the Trusopt into the left eye. During an interview on 10/26/2022 at 12:20 p.m., LVN 10 reviewed Resident 10's Medication Administration Record (MAR) and stated the resident took both eyes drops one right after the other. LVN 10 reviewed the Alphagan eye drop label and stated the eye drops were administered into the left eye without waiting three to five minutes per the medication label instructions. LVN 10 stated she did not know why the eye drops should be administered three to five minutes apart, but she should have followed the labeled medication administration orders. During an interview on 10/27/2022 at 12:30 P.M., the Director of Nursing (DON) stated the importance of following the physician's order to wait five minutes between eye drops, was so the medication would be absorbed and to be able to assess if there was a side effect or reaction to each medication. The DON stated the facility policy was to always follow the physician orders for eye drops. A review of the policy and procedures titled, Eye Medication Administration, last reviewed 7/28/2022, indicated the purpose of the policy and procedure was to administer eye medication as per M.D. order. The policy procedure indicated to wait three to five minutes between more than one drop or more than one medication, this will allow medication time to be absorbed. c. A Review of Resident 47's Record of admission indicated the facility admitted the resident on 4/14/2016 and readmitted the resident on 11/12/2020, with diagnoses that included chronic respiratory failure (a condition where not enough oxygen passes from the lungs into the blood), gastrostomy tube (g-tube, a surgical procedure for inserting a tube through the stomach for feeding or drainage), and fibromyalgia (a long-lasting disorder that causes pain and tenderness throughout the body). A Review of Resident 47's Minimum Data Set (MDS, an assessment and care screening tool) dated 8/8/2022 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 47's physician's orders dated 3/5/2021, indicated an order for lyrica (a controlled pain medication) 50 milligrams (mg, unit of measure) to administer every 12 hours by g-tube for fibromyalgia. During an inspection of Medication Cart 6 on 10/28/2022 at 9:55 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed the Controlled Drug Record (a log signed by the licensed nurse with the date and time a controlled substance was removed from the locked narcotic drawer), the Lyrica bubble pack (packaging in which medications are organized and sealed between cardboard backing and clear plastic cover), and Resident 47's Medication Administration Record (MAR, a document used to record the date and time medication administration). LVN 1 stated there was a discrepancy; Lyrica was documented on the MAR as administered on 10/13/2022 at 9:00 a.m. but was not documented as removed from the Controlled Drug Record. During a concurrent interview and record review with LVN 1 on 10/28/2022 at 10:55 a.m., LVN 1 stated Lyrica was signed as administered on the MAR but was not given based on the signatures on the Controlled Drug Record and the count of the Lyrica bubble pack. LVN 1 further stated, the nurse probably signed it (the MAR) but forgot to pull the medication. LVN 1 stated, the process of giving controlled substance medication was to review the MAR, have a second licensed nurse witness and sign the removal of the controlled drug, administer the medication, and then the primary nurse would document administration on the MAR. LVN 1 stated, Resident 47 could be in more pain if a dose was not administered. LVN 1 stated, Resident 47's pain assessment dated [DATE] during the 7 a.m. to 7 p.m. shift indicated no pain. During a concurrent interview and record review on 10/28/2022 at 12:37 a.m. with the Director of Nurses (DON), the DON confirmed Lyrica was signed on Resident 47's MAR but was not removed from the bubble pack. The DON stated the administering nurse made an error and signed the MAR without administering the medication. The DON stated the importance of properly administering Lyrica is to maintain pain management for Resident 47. The licensed nurse who documented Lyrica was administered on the MAR for Resident 47 on 10/13/2022 was unavailable for interview. A review of the facility's Policy and Procedure titled Medication Pass, last revised 5/2020 indicated the purpose of the policy was to provide guidance on how to properly complete a Medication Pass. The policy indicated the procedure included to check the medication against the MAR to be correct, give medications as ordered, after medications has been given sign the MAR. A review of the facility's Policy and Procedure titled, Narcotics, last reviewed 7/28/2022, indicated narcotics will be accounted for and administered as per physician order safely. The primary nurse will carry the narcotic key and be the only person who has direct access to them. All narcotics administered must be double signed by two licensed nurses after witness of administration. d. A review of Resident 56's Record of admission indicated the facility admitted the resident on 6/3/2019 with diagnoses that included chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), tracheostomy (a surgically created hole [stoma] on the windpipe [trachea] that provides an alternative airway for breathing), gastrostomy (g-tube - a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube), and cardiac arrest (a sudden, unexpected loss of heart function, breathing, and consciousness). A review if Resident 56's History and Physical dated 8/3/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 56's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/1/2022, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident was totally dependent on staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 56's Physician's Orders indicated, diltiazem 90 mg via g-tube every 6 hours hold for systolic blood pressure (SBP - the top number, measures the pressure in your arteries when your heart beats) less than 90 or heart rate (HR) less than 60 per minute for sinus tachycardia (a type of irregular heartbeat that is faster than normal heart rhythm) on 8/15/2022. During an observation of Med Cart 2 (medication storage cart) on 10/26/2022 at 3:58 p.m.,observed Resident 56's bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) for 10/17/2022 6 p.m. dose of diltiazem 90 mg via g-tube every 6 hours hold SBP less than 90 or HR less than 60 per minute was not removed from the bubble pack. During a concurrent interview and record review on 10/26/2022 at 4:15 p.m. with Licensed Vocational Nurse 9 (LVN 9), the Medication Administration Record indicated diltiazem was administered on 10/17/2022 at 6 p.m. with blood pressure of 107/72 and HR of 88 per minute. LVN 9 stated medication was signed by another licensed nurse as given and the medication should not have been left in the bubble pack. LVN 9 stated medication should have been administered as ordered because the vital signs are within the parameter (factor or limit which affect the way that something can be done or made). LVN 9 stated it had the potential for Resident 56 to experience uncontrolled heart rate and increased blood pressure if medication was not administered. During an interview on 10/27/2022 at 4:00 p.m., the Director of Nursing (DON) stated that medication should have been administered as ordered and should not have been left in the bubble pack as the SBP and HR are within the parameters set by the physician. The DON stated the 10 Patient Rights for giving medications (should have been followed by the licensed nurse). The DON stated it had the potential for Resident 56 to develop an uncontrolled HR and high blood pressure. A review of the facility's policy and procedure on Medication Pass, last reviewed on 7/28/2022 indicated, give medications as ordered and follow the 10 Patient Rights of giving medications. A review of the facility's policy and procedure titled 10 Medication Rights, last reviewed on 7/28/2022, indicated: Right Time - Administering medications at a time that was intended by the prescriber. Some medications have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. Right Documentation - Your documentation of the medication must de done at the time that you give the medications. Based on observation, interview, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) by failing to: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for one of one sampled resident (Resident 30). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. 2. Ensure Licensed Vocational Nurse 10 (LVN 10) administered eye drop medication with five minutes between eye drops given in the same eye for one of four sampled residents (Resident 11) investigated during Medication Pass Observation task. This deficient practice had the potential to affect adequate absorption of the medication. 3. Accurately dispense one controlled medication (medication that are considered to have a strong potential for abuse) for one of one resident (Resident 47) in one of 11 medication carts (Medication Cart 6) investigated during the Medication Storage and Labeling facility task. This deficient practice had the potential for an increased risk for unnecessary pain for Resident 47. 4. Ensure that a licensed nursing staff administered diltiazem (medication used to lower blood pressure, slows your heart rate and relaxes the blood vessels [a tube through which the blood circulates in the body]) as ordered for one out of four sampled residents (Resident 56) investigated under the Medication Storage and Labeling task. This deficient practice had the potential for Resident 56 to develop complications such as uncontrolled heart rate and high blood pressure. Findings: a. A review of Resident 30's Record of admission indicated the facility admitted the resident on 5/14/2015 and readmitted the resident on 7/20/2022 with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), encounter for attention to tracheostomy (a tube inserted through a cut in the neck below the vocal cords to allow air to enter the lungs), and heart failure (heart is not pumping as well as it should be). A review of Resident 30's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/5/2022 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 30's physician's orders indicated the following: - Percocet (medication that treats moderate to severe pain) 10/325 milligrams (mg-unit of measurement) 1/2 tab via g-tube (gastrostomy tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach) every four (4) hours as needed (PRN) for moderate pain, ordered on 9/16/2022. - Percocet 10-325 mg 1 tab via g-tube every 4 hours PRN for severe pain, ordered on 9/16/2022. - Morphine (medication that treats moderate to severe pain) 2 mg via g-tube every 4 hours PRN for severe pain, ordered on 9/16/2022. During a concurrent interview and record review on 10/27/2022 at 2:27 p.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 30's Controlled Drug Record (CDR) and Medication Administration Record (MAR) and LVN 4 verified the following: - One dose of Percocet 10-325 mg 1 tab documented on the CDR for 10/2/2022 was not documented on the MAR. - One dose of Percocet 10-325 mg 1/2 tab documented on the CDR for 10/4/2022 was not documented on the MAR. - Two doses of Percocet 10-325 mg 1 tab documented on the CDR for 10/10/2022 was not documented on the MAR. - One dose of Morphine 2 mg documented on the CDR for 10/10/2022 was not documented on the MAR. - One dose of Morphine 2 mg documented on the CDR for 10/12/2022 was not documented on the MAR. - One dose of Morphine 2 mg documented on the CDR for 10/16/2022 was not documented on the MAR. - One dose of Morphine 2 mg documented on the CDR for 10/18/2022 was not documented on the MAR. - One dose of Morphine 2 mg documented on the CDR for 10/19/2022 was not documented on the MAR. - One dose of Morphine 2 mg documented on the CDR for 10/20/2022 was not documented on the MAR. - One dose of Morphine 2 mg documented on the CDR for 10/26/2022 was not documented on the MAR. LVN 4 stated the procedure when giving controlled pain medications was to assess for pain and resident's pain scale. LVN 4 stated nonpharmacological interventions are done first and try to make the resident comfortable. LVN 4 stated if that doesn't work, give medication according to pain scale. LVN 4 stated to take the medication out of the bubble pack, document on the CDR, give the medication to the resident, and then document on the MAR. LVN 4 stated entries on the CDR should have been documented on the MAR. During an interview on 10/27/2022 at 4:39 p.m., with the Director of Staff Development (DSD) and the Director of Nursing (DON), the DON stated the licensed nurse is to assess resident for pain and try nonpharmacological interventions first before giving medication such as repositioning, checking if the resident is dirty, or if they need to defecate. The DON stated the licensed nurse is to check the effectivity of the medication after an hour and notify the physician if it is not effective. The DSD stated documentation is important because it makes you follow-up with the medication and to make sure it is effective and to see if there's a pattern. The DSD stated documentation is important to see if the resident is getting medication left and right and having chronic pain. The DSD stated if you don't document then it makes it look like the resident is not having pain anymore. The DSD stated it is important to document on the MAR to show the medication was given. The DSD stated if it is not documented, it means it was not given. A review of the facility's policy and procedure titled, Medication Pass, last reviewed on 7/28/2022, indicated, After medication has been given sign the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 85's Face Sheet indicated the facility admitted the resident, on 6/3/2022, with diagnoses that included tracheostomy (is an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube) and gastrostomy (is a surgical procedure used to insert a tube through the abdomen and into the stomach), anemia (happens when a person doesn't have the normal amount of red blood cells), and intracranial injury (a violent blow or jolt to the head or body). A review of Resident 85's History and Physical (H&P), dated 6/4/2022, indicated the resident did not have the capacity to understand and make decisions. Resident 85 had traumatic brain injury (TBI- happens when a sudden external, physical assault damages the brain) and status post craniotomy (any surgical incision into the skull). A review of Resident 85's MDS, dated [DATE], indicated the resident could not make self-understood and had no ability to understand others. Resident 85 had severely impaired cognitive skills (gaining of knowledge and understanding) for daily decision making. The MDS indicated Resident 85 was on anticoagulant. A review of Resident 85's physician orders, dated 6/6/2022, indicated an order for Lovenox 40mg sq once daily for deep vein thrombosis prophylaxis (DVT PPX- pharmacologic measures to diminish the risk of forming blood clots in the deep veins) until further notice. During an interview on 10/26/2022 at 10:11 a.m., the Pediatric Nurse Manager (PNM) stated Pharm came once a month to do the MRR on each resident. The PNM stated the Pharm recommended changes to residents' medication when there were irregularities. During an interview, on 10/26/2022 at 11:07 a.m., the Pharm stated when she reviewed the drug regimen of Resident 85, she did not notice the order for Lovenox without duration. During an interview, on 10/28/2022, at 1:23 p.m.,the Pharm stated she only found out that there was an anticoagulant order for Resident 85 on 10/24/2022. She stated she reviewed the anticoagulant (Lovenox sq) and she would be suggesting to the primary physician of the resident to have a stop date (a date established by an appropriate authority which indicates when medication will no longer be administered) for the medication and she would not advise the primary physician to use the order for anticoagulants (blood thinner) stating to use until further notice. During an interview, on 10/31/2022 at 8:08 a.m., the Pharm stated that prolonged use of anticoagulants could cause side effects such as bleeding. During an interview, on 10/31/2022 at 9 a.m., the PNM stated she did not receive any recommendation from Pharm regarding the anticoagulant medication (Lovenox sq) of Resident 85. A review of the facility's Medication Regimen Review activity, dated 10/2/2022 until 10/5/2022, indicated the medications of Resident 85 was reviewed without any recommendations. A review of the facility's recent policy and procedure titled, Medication Regimen Review, revised 3/2022, indicated that medication review will be done by the pharmacy consultant monthly with recommendation if needed. Physicians will evaluate all medications upon their visits. Based on interview and record review, the facility failed to follow and implement its medication regimen review (MRR - a thorough evaluation of the drug regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) policy and procedure, for four of seven sampled residents (Residents 30, 64, 79, and 85) as evidenced by: 1. Failure to report an inadequate indication for Resident 79's Metronidazole's (antibiotic, medication used to treat bacterial infections) use ordered for loose stools. In addition, the facility did not specify a duration upon conducting monthly MRRs. This deficient practice placed Resident 79 at risk of receiving unnecessary medication and had the potential for adverse consequences from prolonged use of antibiotics. 2. Failure to review Resident 85's anticoagulation (keeping the blood thin) medication (Lovenox - an anticoagulant) ordered subcutaneously (sq- beneath, or under, all the layers of the skin) duration of use. The deficient practice had the potential to cause adverse (unfavorable) side effects to residents due to prolonged use. 3. Failure to act upon the facility's consultant pharmacist's (Pharm) recommendation for Resident 64's oxycodone (medication that treats moderate to severe pain) PRN (as needed) order. This deficient practice had the potential to cause adverse side effects from the continued use of these medications. 4. Failing to act upon the facility's Pharm recommendation for Resident 30's Percocet (medication that treats moderate to severe pain) and Morphine (medication that treats moderate to severe pain) PRN order duplicate therapy. This deficient practice had the potential to cause adverse side effects from the continued use of these medications. Findings: a. A review of Resident 79's Face Sheet indicated the facility admitted the resident on 3/9/2017 with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), dependence on ventilator (machine that helps patients breathe when they cannot breathe on their own), and hypoxic ischemic encephalopathy (brain dysfunction caused by lack of blood flow and oxygen to the brain). A review of Resident 79's History and Physical Progress Note, dated 11/1/2021, indicated resident had a history of ethylmalonic encephalopathy (inherited early onset progressive disorder affecting the brain, gastrointestinal tract, and blood vessels). A review of Resident 79's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/12/2022, indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS further indicated Resident 79 was totally dependent on staff for activities of daily living (ADL - activities related to personal care) that included bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 79's physician's order, ordered on 4/19/2017, indicated an order for Metronidazole 187 milligrams (mg - unit of measurement) via gastrostomy tube (g-tube, feeding tube placed through the abdomen into the stomach to provide nutrition and medication) every eight hours (q8h) for loose stool. A review of Resident 79's Medication Record, dated 4/2017, indicated Metronidazole 187 mg was administered via g-tube q8h, from 4/19/2017 to 4/30/2017. A review of Resident 79's Medication Record, dated 7/2020 indicated Metronidazole 187 mg was administered via g-tube q8h, from 7/1/2020 to 7/31/2020. A review of Resident 79's Medication Record, dated 10/2022, indicated Metronidazole 187 mg was administered via g-tube q8h, from 10/1/2022 to 10/28/2022. A review of the Pharm's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations, dated 2/2022 to 10/2022, indicated there were no recommendations for Resident 79 during the consultant pharmacist's visit. During an interview, on 10/31/2022 at 8:08 a.m., the Pharm stated she conducted MRR once a month and reviewed the medications for every resident in the facility including pediatric (children) residents. The Pharm stated she would review the order recap and look for newly ordered medications and try to identify irregularities that included reviewing for appropriate indication, dose, and duration. The Pharm stated she monitored and evaluated antibiotic use and checked for the right indication, dosing, length of therapy, and for any possible drug interactions. The Pharm verified Resident 79's physician order for Metronidazole 187 mg via g-tube for loose stools with a start date of 4/19/2017. The Pharm stated a recommendation for Metronidazole was last made on 6/2017 by the previous pharmacist questioning the length of therapy and asking what the stop date was. The response from the physician was that the antibiotic was recommended by Resident 79's geneticist (doctor for inherited characteristics) for maintenance for the diagnosis of ethylmalonic encephalopathy. Upon reviewing the order, the Pharm verified Resident 79's order for Metronidazole did not have a duration indicating the length of therapy and stated antibiotic orders should have a duration and a stop date to justify its use. The Pharm explained the duration for Metronidazole normally ranged from five to 14 days depending on what was being treated. The Pharm also confirmed loose stools was not an adequate indication for why the antibiotic should be given and stated the order should have been clarified with the physician. The Pharm stated that she was aware of the irregularities regarding Resident 79's Metronidazole order and thought it was strange. However, the Pharm confirmed she did not make any recommendations and report the irregularities concerning Resident 79's Metronidazole since she began as the consultant pharmacist for the facility from January 2022. The Pharm stated the irregularities should have been reported to the Director of Nursing (DON) to follow up with the physician to clarify the order and if the resident still needs to be on the antibiotic for maintenance since the last recommendation made on 6/2017 by the previous pharmacist. The Pharm stated long term antibiotic use could potentially result in changes in the gut flora and can lead to antibiotic resistance. During an interview, on 10/31/2022 at 8:58 a.m., the DON confirmed she did not receive a written report of pharmacy recommendation regarding Resident 79's Metronidazole order and verified there were no recommendations from pharmacy for Resident 79 from 1/2022 to 10/2022. A review of the facility's policy and procedure titled, Antibiotic Therapy, last reviewed on 7/28/2022, indicated the physician's order for antibiotics must include the following: the name, dose, frequency, duration, and the reason for the antibiotic. A review of the facility's policy and procedure titled, Medication Regimen Review, last reviewed on 7/28/22, indicated a complete review of all aspects of care including medication is done quarterly at the IDT meeting with the medical director and IDT staff for pediatrics. The policy and procedure further indicated the pharmacy consultant will do regimen review of medications monthly and make recommendations as needed and that a drug regimen review will include medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potential clinically significant medication adverse consequences. c. A review of Resident 64's Face Sheet indicated the resident was admitted to the facility on [DATE] with a readmission date of 5/20/2022 with diagnosis that included chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), encounter for attention to gastrostomy (G-tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach), and end stage renal disease (chronic irreversible kidney failure). A review of Resident 64's MDS, dated [DATE], indicated the resident was in a persistent vegetative state (absence of responsiveness). A review of Resident 64's physician's orders indicated an order for oxycodone 5 mg via g-tube every six (6) hours for pain not to exceed 3 gm (gram- a unit of measure) APAP (acetaminophen- medication used to treat minor aches and pains and reduces fever) from all sources for 24 hours. A review of Resident 64's MRR for the month of 9/2022 indicated resident had an order for oxycodone 5 mg via g-tube every 6 hours for pain, not to exceed 3 grams of APAP from all sources for 24 hours. The MRR indicated oxycodone did not have APAP in it, and if it did it was supposed to be Percocet (oxycodone/APAP) or to change it to not to exceed four PRN doses for 24 hours. During a concurrent interview and record review, on 10/28/2022 at 8:42 a.m., with the Director of Nursing (DON), Resident 64's MRR for 9/2022 was reviewed. The DON verified Resident 64 had the same order currently for oxycodone and stated the order had not changed. The DON verified there was no documented evidence recommendations were followed through and there were no notes to the physician. The DON stated pharmacist recommendations should be followed through. The DON stated it was important in order to have the effectivity of the medication and important having the right medication for the resident especially the right dosage. A review of the facility's policy and procedure titled, Medication Regimen Review, last reviewed on 7/28/2022, indicated, To ensure proper medication review .Medication review will be done by the pharmacy consultant monthly with recommendation if needed .Physicians will evaluate all medications upon their visits .A drug regimen review will include medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potential clinically significant medication adverse consequences. d. A review of Resident 30's Face Sheet indicated the resident was admitted to the facility on [DATE] with a readmission date of 7/20/2022 with diagnosis that included chronic respiratory failure, encounter for attention to tracheostomy (a tube inserted through a cut in the neck below the vocal cords to allow air to enter the lungs), and heart failure (heart is not pumping as well as it should be). A review of Resident 30's MDS, dated [DATE], indicated the resident had the ability to make self-understood and has the ability to understand others. A review of Resident 30's physician's orders indicated the following: - Percocet 10-325mg 1/2 tab via g-tube every four (4) hours as needed for moderate pain, ordered on 9/16/2022. - Percocet 10-325mg 1 tab via g-tube every 4 hours as needed for severe pain, ordered on 9/16/2022. - Morphine 2mg via g-tube every 4 hours as needed for severe pain, ordered on 9/16/2022. A review of Resident 30's MRR for the month of 9/2022 indicated resident had an order for Morphine 2 mg via g-tube every 4 hours PRN (as needed) for severe pain and Percocet 10-325 mg one tab via g-tube every 4 hours PRN for severe pain. The MRR indicated to please clarify overlapping PRN indication, and which one should be given for severe pain. A review of Resident 30's MRR for the month of 10/2022 indicated resident had an order for Morphine 2 mg via g-tube every 4 hours PRN for severe pain and Percocet 10-325 mg one tab via g-tube every 4 hours PRN for severe pain. The MRR indicated to please clarify overlapping PRN indication and which one should be given for severe pain. During a concurrent interview and record review, on 10/28/2022 at 8:59 a.m., with the Director of Nursing (DON), Resident 30's MRR for 9/2022 and 10/2022 were reviewed. The DON verified Resident 30's MRR recommendations and there were no comments for the recommendations. The DON verified both medications were still active and that there was no documented evidence that recommendations were followed though. The DON stated she needed to clarify with the physician about which medication was to be used for severe pain. The DON stated pharmacist recommendations should be followed through. The DON stated it was important in order to have the effectivity of the medication and important having the right medication for the resident especially the right dosage. A review of the facility's policy and procedure titled, Medication Regimen Review, last reviewed on 7/28/2022, indicated, To ensure proper medication review .Medication review will be done by the pharmacy consultant monthly with recommendation if needed .Physicians will evaluate all medications upon their visits .A drug regimen review will include medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potential clinically significant medication adverse consequences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. During an observation and interview on 10/26/2022, at 1:29 p.m., with Licensed Vocational Nurse 4 (LVN 4), observed the following in Medication Cart 8: - glucometer test strips with no open dates expiring 5/2023 - control solutions without open dates expiring 2/21/2023. - Humulin R insulin vial (short acting insulin to control blood sugar) no open date, expiration date of 5/2023. LVN 4 stated that the glucometer test strips and the control solutions should have been placed with an open date to determine when to discard them. LVN 4 also stated that drugs and biologicals stored in the medication cart should also have open dates to determine the discard date. During an observation of Medication Cart 99 and interview on 10/27/2022 at 4:06 p.m., with Registered Nurse 1 (RN 1), observed Resident 69's levetiracetam 100 mg/ml solution with no open date, expiring 10/23/23. RN 1 stated that the levetiracetam solution should have indicated an open dated to determine the discard date of the medication. A review of the facility's current Glucometer (a small portable machine that's used to measure how much sugar is in the blood) Manufacturer's Recommendation for use (Evencare 63), dated 2016, indicated that test strips can be used within 6 months of first opening or the expiration date on the label, whichever comes first. Newly opened bottles of control solutions must be marked with the date opened on the space provided on the control solution labels. A review of the facility's current policy and procedure titled Storage of Insulin, revised 7/2021, indicated that when a new insulin bottle is open make sure to write the open date on the container. Insulin is good for 28 days once opened. A review of the facility's current policy and procedure titled, Medication Labeling, revised date of 7/28/2022, indicated that over the counter medications/house supply medications once opened will be labeled with the open date. Patient specific over the counter medication/ house supply medications (i.e. eye drops) will be labeled with an open date and the patient's name. Liquid prescriptions medication when opened will be labeled with an open date. Vials with multiple doses when opened will be labeled with an open date. Based on observation, interview and record review, the facility failed to: 1.Ensure the Keppra (a medication used to treat seizures [abnormal electrical activity in the brain]) bottle was properly labeled or had a directions changed refer to chart sticker for one of four sampled residents (Resident 78) investigated during a Medication Pass Observation with Medication Cart 7. This deficient practice had the potential to result in the mismanagement of seizures for Resident 78. 2. Discard expired insulin (hormone that lowers the level of glucose [sugar] in the blood) for two of two residents (Resident 33 and 74) and expired metoprolol tartrate (blood pressure medication) for Resident 29 that were observed in three of 11 medication carts (Medication Cart 1, 5, and 10) that were reviewed during the facility task Medication Storage and Labeling. These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medications and inaccurate blood glucose readings. 3. Label opened glucometer (medical device for determining the approximate concentration of glucose in the blood) test strip (an absorbent strip that soaks up blood to be read by the glucometer) containers found in four of 11 medication carts (Medication Cart 1, 5, 8, and 99) that were reviewed during the facility task Medication Storage and Labeling. These deficient practices had the potential to result in inaccurate blood glucose readings. 4. Label open glucometer control solutions (solutions used to test the glucometer for proper function) found in (Medication Cart 1, 4, 8, and 99 for three residents (Residents 33, 6, and 15) that were reviewed during the facility task Medication Storage and Labeling. These deficient practices had the potential to result in inaccurate blood glucose readings. 5.Properly label drugs and biologicals (drugs derived from natural sources), found in five of 11 medication Carts (Medication Cart 1, 4, 8, 10, and 99) that were reviewed during the facility task Medication Storage and Labeling. These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medications and the potential to result in cross contamination (the transfer of bacteria or viruses from one person to another) between residents. 6. Discard two expired 0.9 percent (%) sodium chloride (normal saline or NS, a solution of water and salt given intravenously [IV, through a vein]) bags, 20 heparin flushes (a solution used to flush [clean out] an IV catheter [a tube, placed in a vein, used to administer medication]), and an expired IV flow regulator extension set (tubing with a dial, used to regulate the flow of fluid through an IV) observed in one of two medication storage rooms (Pediatric Medication Storage Room) that were reviewed during the facility task Medication Storage and Labeling. These deficient practices had the potential to result in harm to residents from compromised quality, strength, or purity of expired medications and tubing. 7. Ensure temperatures were documented on the Refrigerator #4 temperature log observed in one of two medication storage rooms (Adult Medication Storage Room) that was reviewed during the facility task Medication Storage and Labeling. This deficient practice had the potential to compromise the therapeutic effectiveness of the stored medications. Findings: a. A review of Resident 78's Record of admission indicated the facility admitted the resident on 12/27/2018 with diagnoses that included chronic respiratory failure (a condition where not enough oxygen passes from the lungs into the blood), gastrostomy tube (g-tube, a surgical procedure for inserting a tube through the stomach for feeding or drainage) and seizures. A review of Resident 78's History and Physical dated 2/16/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 78's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/16/2021 indicated Resident 78 was totally dependent on staff for mobility, dressing, eating, toilet use, and personal hygiene. A review of the physician's order indicated the following medication orders: -Keppra 750 milligrams (mg, a unit of measurement) via g-tube, every 12 hours for seizures, dated 9/11/2022. -Keppra 500 milligrams via g-tube every 12 hours at 6 a.m. and 6 p.m. for seizures, dated 9/11/2022. During a Medication Pass Observation on 10/26/2022 at 9:13 a.m., Registered Nurse 2 (RN 2) prepared Resident 78's medications at Medication Cart 7. RN 2 reviewed Resident 78's Keppra bottle and stated the label indicated the medication was to be given at 12 p.m. and 12 a.m. RN 2 stated Resident 78 was currently receiving 750 mg of Keppra every twelve hours at 9 a.m. and 9 p.m. per the physician's order and the Medication Administration Record (MAR). RN 2 stated the label did not match the physician's order and the MAR and there should have been a directions changed refer to chart sticker to indicate there was a change, but it was not present. RN 2 stated she would call the pharmacy to notify them of the discrepancy and she would place a directions changed refer to chart sticker on the bottle. During an interview on 10/26/2022 at 12:43 p.m., RN 2 stated the importance of having the sticker (directions changed refer to chart) was to make sure the correct dosage was given at the right time. RN 2 stated if the sticker was not there and the label and MAR did not match, a medication error could occur. During an interview on 10/27/2022 at 12:35 p.m., the Director of Nursing (DON) stated if the (medication) bottle and MAR or physician's order are different, then they (staff) need to call pharmacy and use a change of direction sticker. The DON stated the Keppra label should have matched the order and MAR. A review of the facility policy and procedures titled, Medication Labeling, last reviewed 7/28/2022, indicated the purpose of the policy is to provide a guideline on how to label medication. If an order is changed on a prescription medication a directions changed refer to chart sticker will be placed on medication with the change. b. A review of Resident 33's Record of admission indicated the facility admitted the resident on 10/13/2008 and readmitted the resident on 2/14/2019 with diagnoses that included chronic respiratory failure (a condition where not enough oxygen passes from the lungs into the blood) and type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 33's Minimum Data Set (MDS- an assessment and care screening tool) dated 8/1/2022 indicated Resident 33 sometimes had the ability to make self-understood and sometimes had the ability to understand others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 33's Physician Orders indicated the following orders: -NPH Insulin (an intermediate acting medication used to treat high blood sugar) 16 units (a measurement) subcutaneously (SQ, under the skin) every 12 hours, hold (do not administer) if the blood sugar (BS) is less than 100 for DM, dated 2/14/2019. -Fingerstick blood sugar check twice a day with regular insulin (also known as Novolin R, a short acting medication to treat high blood sugar) per sliding scale (a scale with insulin dosage variations to be administered based on blood sugar levels), dated 2/14/2019. During a Medication Storage Observation on 10/26/2022 at 10:33 A.M., Licensed Vocational Nurse 11 (LVN 11) reviewed Medication Cart 1 and stated there was the following: - One Novolin R insulin vial labeled for Resident 33 with an open date (date written on a medication when it was first opened for use) of 9/18/2022. LVN 11 stated the insulin expired after 28 days on 10/16/2022. LVN 11 stated the insulin should not have been available in the cart or administered after 10/16/2022. LVN 11 stated the importance of not storing or using expired insulin was the integrity of the insulin could be compromised and may not be effective. LVN 11 stated it could affect the overall management of the resident's blood sugars. -One bottle of Evencare G3 (a brand name) Blood Glucose Test Strips and two bottles of Evencare G3 Control Solutions were inside Resident 33's blood glucose meter (BGM-glucometer) kit bag with no labeled open dates. LVN 11 reviewed the Evercare Test Strips package insert (a document that provides information for use) and stated there should be an open date because they expire after six months. LVN 11 stated she was unsure if the control solutions needed to be labeled with an open date. - One Humulin N insulin vial, located in the top drawer of the medication cart, was not labeled. LVN 11 stated there was no labeled open date and no label to identify which resident (the medication belonged to). LVN 11 stated the importance of labeling medications was that medications should not be used for more than one resident. LVN 11 stated she would discard the medication because she did not know who it belonged to and when it was opened. During an interview on 10/26/2022 at 11:36 a.m., LVN 11 reviewed the Evencare G3 Glucose Control Solution package insert and stated the control solutions should be labeled with an open date. LVN 11 stated the control solutions needed an open date because they expired 90 days after opening. LVN 11 stated if the BGM did not get accurately calibrated (measurements are adjusted in comparison to a certain standard, to make sure a glucometer is read accurately), it could lead to inaccurate resident blood sugar readings. During an interview on 10/27/2022 at 4 p.m. with the Director of Nursing (DON) and the Director of Staff Development (DSD), the DON stated insulin should always have an open date because it is discarded after 28 days and replaced. The DON stated if the insulin was expired it could lead to ineffective medication and high blood sugars. The DON stated only one vial of insulin is used per resident and it should be labeled, it is the resident's medication. The DON stated if a vial of insulin is unlabeled, it should be discarded. The DON stated the importance of labeling medications is to prevent cross contamination and infection control issues. The DON stated every resident had their own glucometer and it was calibrated daily. The DON stated the test strips and control solutions should have an open date because it could affect the blood sugar readings if they were expired. A review of the facility policy and procedures titled, Storage of Insulin, last reviewed 7/28/2022, indicated the purpose of the policy is to provide guidelines for proper insulin storage. After opening insulin, it will be kept in the medication cart for 28 days. When a new bottle of insulin is open make sure to write the open date on the container. Insulin is goof for 28 days once opened. A review of the facility policy and procedures titled, 10 Medication Rights last reviewed 7/28/2022, indicated the purpose of the policy is to provide current guidelines for medication patient rights. Right patient - compare the individual's name on the prescription label and the Medication Administration Record (MAR). Right medication- read the medication label carefully, and compare to the MAR. Right dose- compare the dose of the medication to the MAR. Check the expiration date. A review of the Evencare G3 manufacturer's package insert, undated, indicated the Blood Glucose Test Strips are to be used with the Evencare G3 Blood Glucose Meter to quantitatively measure glucose in capillary blood taken from a fingertip, palm, or forearm. Use (strips) within six months of first opening or the expiration date on the label, whichever comes first. A review of the Evencare G3 manufacturer's package insert, undated, indicated the Glucose Control Solutions test is to validate the performance of the blood glucose monitoring system using a testing solution with a known range of glucose. A control test that falls withing the acceptable range indicates the user's technique is appropriate and the meter and test trip are functioning properly. Newly opened bottles of control solutions must be marked with the date opened on the space provided on the control solution labels. Discard any unused control solutions 90 days after opening or after expiration date, whichever comes first. c.1. A review of Resident 6's Record of admission indicated the facility admitted the resident on 12/24/2021 with diagnoses that included respiratory failure and type 2 DM. A review of Resident 6's MDS dated [DATE] indicated Resident 6 was totally dependent on staff for mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 6's Physician Orders indicated the following order: -Fingerstick blood sugar check every 6 hours with regular insulin per sliding scale, dated 1/3/2022. c.2. A review of Resident 15's admission Record indicated the facility admitted the resident on 12/29/2021 with diagnoses that included chronic respiratory failure and type 2 DM. A review of Resident 15's MDS dated [DATE] indicated Resident 15 was totally dependent on staff for mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 15's Physician Orders indicated the following orders: -NPH Insulin 40 units SQ, every 12 hours, hold if the BS is less than 100 for DM, dated 10/17/2022. -Fingerstick blood sugar check every 6 hours with regular insulin per sliding scale, dated 1/3/2022. During a Medication Storage Observation on 10/26/2022 at 10:33 a.m., LVN 6 reviewed Medication Cart 4 and stated there was the following: - Two bottles of Evencare G3 Control Solution inside Resident 6's BGM kit bag with no labeled open dates. - Two bottles of Evencare G3 Control Solution inside Resident 15's BGM kit bag with no labeled open dates. LVN 6 stated it was important to calibrate glucometers to make sure they were functioning properly. LVN 6 stated it was important to know when the control solutions were opened because they expire. LVN 6 stated if expired solutions were used, then they wouldn't know if the meter calibration was correct and that could affect the insulin dosage and be detrimental to the resident. - One box containing artificial tears (eye drops) not labeled with a resident name. LVN 6 stated the box was labeled with the open date and a room number, but no resident name. LVN 6 stated there should be a resident name because patients can move from room to room. LVN 6 stated not labeling a resident's name leaves room for a medication error and the eye drops could be given to the wrong patient. During an interview on 10/27/2022 at 4 p.m., with the Director of Nursing (DON) and the Director of Staff Development (DSD), the DON stated eye drops are over-the-counter medications that are labeled when opened with the resident's name, room number, and open date. The DON stated it was important to have a name, not just a room number, because it could lead to the wrong patient receiving the medication. The DON stated the importance of labeling medications is to prevent cross contamination and infection control issues. The DON stated every resident had their own glucometer and it was calibrated daily. The DON stated the test strips and control solutions should have an open date because it could affect the blood sugar readings if they were expired. A review of the facility policy and procedures titled, 10 Medication Rights, last reviewed 7/28/2022, indicated the purpose of the policy is to provide current guidelines for medication patient rights. Right patient - compare the individual's name on the prescription label and the Medication Administration Record (MAR). Right medication- read the medication label carefully, and compare to the MAR. Right dose- compare the dose of the medication to the MAR. Check the expiration date. A review of the Evencare G3 manufacturer's package insert, undated, indicated the Blood Glucose Test Strips are to be used with the Evencare G3 Blood Glucose Meter to quantitatively measure glucose in capillary blood taken from a fingertip, palm, or forearm. Use (strips) within six months of first opening or the expiration date on the label, whichever comes first. A review of the Evencare G3 manufacturer's package insert, undated, indicated the Glucose Control Solutions test is to validate the performance of the blood glucose monitoring system using a testing solution with a known range of glucose. A control test that falls withing the acceptable range indicates the user's technique is appropriate and the meter and test trip are functioning properly. Newly opened bottles of control solutions must be marked with the date opened on the space provided on the control solution labels. Discard any unused control solutions 90 days after opening or after expiration date, whichever comes first. A review of the facility policy and procedures titled, Medication Labeling, last reviewed 7/28/2022, indicated the purpose of the policy is to provide a guideline on how to label medications. Over the counter medication/house supply medications (i.e. eye drops) will be labeled with the open date and the patient's name. d. During a Medication Storage Observation of the Pediatric Medication Storage Room on 10/27/2022 at 9:25 a.m., the Assistant Pediatrics Nurse Manager (APNM) stated the following was currently stored in the room: - One, 1000 milliliter (mL, a unit of measurement) 0.9 % sodium chloride (normal saline or NS, a solution of water and salt given intravenously [IV, through a vein]) IV bag dated with an expiration date of 7/2021. - One, 100 mL NS IV bag with an expiration date of 9/2022. -Twenty, 5 mL heparin flushes (a solution used to flush [clean out] an IV catheter [a tube, placed in a vein, used to administer medication]) with expiration dates of 3/2022. The APNM stated the expired IV bags and flushes were stored in the room and readily available for use, but they should have been removed. The APNM stated the charge nurse should audit the medication storage room every shift to ensure nothing is expired. The APNM stated the importance of not storing NS and flushes that are expired is the potential for harm to residents. -One IV flow regulator extension set (tubing with a dial, used to regulate the flow of fluid through an IV) labeled with an expiration date of 2/26/2021. The APNM stated the expired regulator was readily available for use and should have been discarded. During an interview on 10/27/2022 at 9:39 a.m. with the Pediatric Nurse Manager (PNM), the PNM stated the facility process is to turn expired medications and tubing into the DON who would store them in her office until disposal with the pharmacy. The PNM stated the importance of not storing expired items in the medication storage room was that they could be used for a resident. During an interview on 10/27/2022 at 9:45 a.m., the [NAME] President of Operations (VPO) stated if an expired medication was given to a resident, it would be a medication error. During an interview on 10/27/2022 at 9:57 a.m., the DON stated once or twice a week expired fluids and medications are given to her by pediatrics (staff) for disposal. The DON stated expired medications and tubing should not have been kept in the medication storage room. A review of the facility policy and procedures titled, Disposal of expired Intravenous Fluids, IV Tubing Disposal unused, last reviewed 7/28/2022, indicated the purpose of the policy was to ensure the proper disposal of Intravenous fluids and IV tubing disposal unused that have expired. The procedure indicated: 1. When any intravenous fluids, including the tubing has expired it will be given to the Director of Nursing for proper disposal. 2. Medications that are expired such as heparin, normal saline, IV flushes etc, will be disposed of by giving to the Director of Nursing for proper disposal. i. During a concurrent observation and interview, on 10/26/2022 at 1:43 p.m., with Licensed Vocational Nurse 10 (LVN 10), for inspection of Medication Cart 10, observed an opened artificial tear drops with no seal not labeled with the date and the name of the resident it belonged to. LVN 10 confirmed the opened artificial tear drops container was not labeled and stated it should have been labeled with the resident's name and opened date. LVN 10 stated she does not know which resident the artificial tear drops belonged to and stated any unlabeled medications should be discarded. During an interview, on 10/27/2022 at 1:58 p.m., the Director of Nursing (DON) stated all opened medications should be labeled with an open date. The DON explained a blue sticker is used to label opened house supply medications and stated it should have been used to label with an open date. The DON stated the artificial tear drops should have been labeled with proper identification to whom it belonged to so it is given to the right patient for safety issues. The DON stated the licensed nurse should have removed the artificial tear drops from the medication cart and discarded it once it was identified with no name and date to prevent confusion and avoid mistakenly giving it to other residents. The DON further stated the purpose of labeling medications with an open date is for staff to know when it should be discarded and prevent the medication from being given to residents beyond the recommended use by date from opening. The facility's policy and procedure titled, Medication Labeling, last reviewed on 7/28/2022, indicated over the counter medication and house supply medications once opened will be labeled with the open date. The policy and procedure further indicated liquid prescription medication and vials with multiple doses when opened will be labeled with an open date. j. A review of Resident 29's Record of admission indicated the facility admitted the resident on 10/20/2021, and most recently readmitted the resident on 9/19/2022, with diagnoses that included encounter for attention to tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and essential hypertension (high blood pressure that's not the result of a medical condition). A review of Resident 29's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/27/2022, indicated the resident's cognitive skills (thought processes) for daily decision making was moderately impaired. A review of Resident 29's physician's order, ordered on 12/25/2021, indicated an order for metoprolol tartrate 25 milligrams (mg-unit of measure) take one tab via gastrostomy tube (g-tube, feeding tube placed through the abdomen into the stomach for delivery of nutrients and medications) daily (QD) as needed (PRN) for systolic blood pressure (SBP - measures the pressure the blood is exerting against the artery walls when the heart beats) greater than 150/90 for hypertension (elevated blood pressure). During a concurrent observation and interview, on 10/26/2022 at 1:43 p.m., with Licensed Vocational Nurse 10 (LVN 10), for inspection of Medication Cart 10, observed Resident 29's PRN metoprolol bubble pack (individually sealed compartments that hold medication) with an expiration date of 10/21/2022 in the medication cart. LVN 10 verified the medication is expired and stated the bubble pack should have been removed from the medication cart. During an interview, on 10/27/2022 at 1:58 p.m., the Director of Nursing (DON) stated expired medications should be removed from the medication cart and given to the DON for proper disposal. The DON explained for non-narcotic medications, she would dispose the medication with another staff to witness and record the disposal. The DON further stated Resident 29's metoprolol should not have been in the medication cart since it was discontinued and the resident is no longer at the facility. A review of the facility's policy and procedure titled, Expired Medications, last reviewed on 7/28/2022, indicated daily checks of the medication carts will be completed by the primary nurse or designee and any expired medications will be given to the Director of Nursing for proper disposal. f. A review of Resident 74's Record of admission indicated the facility admitted the resident on 6/13/2021 with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), end stage renal disease (chronic irreversible kidney failure), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 74's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/19/2022 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 74's physician's orders indicated an order for regular human insulin as per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges), ordered on 11/30/2021. During a concurrent observation of Medication Cart 5 and interview on 10/26/2022 at 12:24 p.m. with Licensed Vocational Nurse 6 (LVN 6), observed Resident 74's Humulin R (type of regular insulin) stored in the medication cart with an open date of 9/26/2022. LVN 6 stated insulin pens are good for 28 days after opening. LVN 6 verified Resident 74's insulin pen was overdue for reordering and stated it should be reordered. During an interview on 10/27/2022 at 3:57 p.m., with the Director of Staff Development (DSD) and Director of Nursing (DON), the DSD stated insulin is good for 28 days once opened. The DSD stated it is important to put an open date because after 28 days insulin has to be discarded and replaced with a new one. The DON stated after 28 days the medication can be less effective and the blood sugar might be high. A review of the facility's policy and procedure titled, Storage of Insulin, last reviewed on 7/28/2022, indicated, Insulin will be stored in the medication refrigerator before opening. After opening insulin will then be kept in the medication cart for 28 days .Insulin is good for 28 days once opened. g. During a concurrent observation of Medication Cart 5 and interview on 10/26/2022 at 12:24 p.m., with Licensed Vocational Nurse 6 (LVN 6), observed an open glucometer test strip container not labeled with an open date stored in the medication cart. LVN 6 stated it should be labeled when it is opened. During an interview on 10/27/2022 at 3:57 p.m., with the Director of Staff Development (DSD) and Director of Nursing (DON), the DON stated the glucometer test strip container should be dated once opened because if it's passed it's use-by date it can be less effective and the blood sugar reading can be wrong. The DON stated it should have been dated once opened. A review of the undated facility-provided manufacture's guidelines titled Evencare Blood Glucose Test Strips, indicated, Use within 6 months of first opening or the expiration date on the label, whichever comes first. h. During a concurrent observation of the Adult Medication Storage Room and interview on 10/26/2022 at 4:01 p.m., with Registered Nurse 4 (RN 4), observed and verified with RN 4 that Refrigerator 4 had missing temperature entries on the log. RN 4 stated the charge nurse for the morning and night shift will check refrigerator temperatures every shift and document on the log. RN 4 stated the temperatures should be checked and documented. RN 4 stated the correct refrigerator temperature is important because medications can be affected. A review of the Refrigerator 4 temperature log indicated, All medications requiring refrigeration shall be stored in the refrigerator between 36 degrees Fahrenheit (°F - scale for measuring temperature) and 46 degrees Fahrenheit. All medication nurses are responsible to ensure that the proper temperature is maintained at all times. Refrigerator temperatures are maintained every shift. Please write the temperature of the refrigerator every shift. Refrigerator 4 temperature log indicated the following: - Missing temperature on 10/3/2022 for the 7 p.m. to 7 a.m. shift - Missing temperature on 10/4/2022 for the 7 p.m. to 7 a.m. shift - Missing temperature on 10/5/2022 for the 7 p.m. to 7 a.m. shift - Missing temperature on 10/15/2022 for the 7 p.m. to 7 a.m. shift - Missing temperature on 10/16/2022 for the 7 p.m. to 7 a.m. shift - Missing temperature on 10/17/2022 for the 7 p.m. to 7 a.m. shift - Missing temperature on 10/20/2022 for the 7 p.m. to 7 a.m. shift - Missing temperature on 10/23/2022 for the 7 p.m. to 7 a.m. shift - Missing temperature on 10/25/2022 for the 7 p.m. to 7 a.m. shift During a concurrent interview and record review of Refrigerator 4 temperature log on 10/27/2022 at 4:49 p.m., with the Director of Nursing (DON), the DON stated the temperature of the medication refrigerators should be between 36 to 46 degrees Fahrenheit. The DON stated the charge nurse for the morning and night shift will check temperatures and document every shift. The DON stated correct temperature is needed because if it's too cold or too hot, medications can have a change in the strength. The DON verified the missing entries on the temperature log and stated it should be documented. The DON also verified temperatures on the log were above the appropriate temperature range. The DON stated temperatures should be adjusted to be at the appropriate range. A review of the facility's[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure opened food items and beverages in the kitchen refrigerator were labeled with an open date (date written when it was first opened for use) for 12 out of 100 residents who receive and consume food from the facility kitchen. These deficient practices placed the residents at risk for developing foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms). Findings: During an initial kitchen observation tour, on 10/24/2022 at 8:05 a.m., observed the following unlabeled food items in the refrigerator: - opened container of fat free milk with no open date - opened container of reduced fat milk with no open date - opened container of almond milk with no open date - opened container of half and half with no open date During a concurrent observation and interview, on 10/24/2022 at 8:05 a.m., Dietary Aide 1 (DA 1) observed and verified the opened containers of fat free milk, reduced fat milk, almond milk and half and half in the refrigerator were not labeled with open dates. DA 1 stated the opened containers of milk, almond milk, and half and half should have been labeled with the date once they were opened and stored in the refrigerator. During a concurrent observation and interview, on 10/26/2022 at 9:13 a.m., the Registered Dietitian (RD) stated opened food items and beverages need to be labeled with an open date per facility policy. The RD explained that milk should be used by the manufacturer's expiration date while almond milk and half and half should be discarded within 14 days of opening. The RD confirmed the kitchen staff should have labeled the container of milk, almond milk, and half and half with the open date for staff to know when the food item needs to be discarded to ensure the quality of the food is preserved and not serve food that is past the recommended date upon opening. A review of the facility's policy and procedure titled, Labeling and Dating of Foods, last reviewed on 7/28/2022, indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The policy and procedure further indicated newly opened food items will need to be closed and labeled with an open date and used by the date that follow the manufacturer's guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Restorative Nurse Assistants (RNA- a healthcare professional who has earned certification as a certified nursing assistant and works with patients trying to return to regular, daily functioning after an illness or injury) failed to document the RNA therapies for four out of four sampled residents (Residents 58, 60, 71, and 84). This deficient practice had the potential for decreased range of motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point) to residents and could lead to inability to evaluate the appropriateness of the care delivered. Findings: a. A review of Resident 58's Record of Admission, indicated that the facility originally admitted the resident on 4/9/2010 and readmitted the resident on 1/20/2022, with diagnoses including debility (weakness of a person's body or mind, especially one caused by an illness), cardiorespiratory (relating to the heart and the respiratory system) conditions, and traumatic brain dysfunction (injury that results from a violent blow or jolt to the head or body). A review of Resident 58's History and Physical (H&P), dated 1/10/2022, indicated that the resident had hypertonic extremities (a condition in which there is too much muscle tone so that arms or legs are stiff and difficult to move). A review of Resident 58's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/21/2022, indicated that the resident cannot make self-understood and had no ability to understand others. The MDS also indicated the resident was on restorative nursing program for active range of motion (AROM- means how far a joint move without assistance). A review of Resident 58's Physician Orders, dated 1/26/2022, indicated an order to provide active assist range of motion to both upper extremities and both lower extremities once a day by RNA weekly, and to left lower extremity include slow prolonged stretching exercises into knee extension as tolerated once a day weekly. A review of Resident 58's Care Plan, dated 7/2022, indicated that the resident had limitations in the functional range of motion in the following areas: minimum limitations on the left knee and moderate limitations on both wrist and thumbs. The goal of the care plan was for the resident not to have further decline in the functional range of motion in the said areas. A review of Resident 58's Restorative Charting Record, indicated missing initial of Restorative Nurse Assistant 3 (RNA 3) on 10/15/2022, on the active assist range of motion to both upper extremities and both lower extremities once a day by RNA weekly. During an interview on 10/26/2022, at 10:04 a.m., with Restorative Nursing Assistant 3 (RNA 3), RNA 3 stated that she did the therapy to Resident 58 on 10/15/2022 but forgot to document it.RNA 3 stated she was aware that if she did not document it, then it was not done. b. A review of Resident 60's Record of Admission, indicated that the facility originally admitted the resident on 9/24/2014 and readmitted the resident on 9/24/2014, with diagnoses including muscle weakness and neuromuscular scoliosis (an irregular spinal curvature caused by disorders of the brain, spinal cord, and muscular system). A review of Resident 60's H&P, dated 2/21/2022, indicated that the resident had progressive neuromuscular scoliosis, severe status post spinal fusion (surgery to permanently join two or more bones in the spine so there is no movement between them) in August 2021. The H&P indicated the resident had flexion contractures (a bent joint that cannot be straightened actively or passively) at wrists, knees, and ankles. A review of Resident 60's MDS, dated [DATE], indicated that the resident cannot make self-understood and had no ability to understand others. The MDS indicated the resident had functional limitation on both upper and lower extremities in range of motion, was on restorative nursing program for active range of motion, and on a splint or brace assistance. A review of Resident 60's Physician Orders, dated 2/21/2022, indicated an order for passive range of motion to all extremities once a day by RNA. A review of Resident 60's Pediatric Physical Therapy Evaluation, dated 3/12/2020, indicated a treatment plan of therapeutic exercises, activities, and functional positioning. A review of Resident 60's Care Plan, dated 1/2022, indicated the resident had limitations in the functional range of motion in the following areas: minimum limitations on the right hip, left knee and moderate limitations on the right knee, both ankles. The goal of the care plan was for the resident not to have further decline in the functional range of motion in the said areas. A review of Resident 60's Restorative Charting Record, indicated missing initial of Restorative Nurse Assistant 2 (RNA 2) on 10/9/2022, on the passive range of motion to all extremities once a day by RNA. During an interview on 10/27/2022, at 3:45 p.m., with Restorative Nursing Assistant 2 (RNA 2), RNA 2 stated that she did the therapy to Resident 60 on 10/9/2022 but forgot to document it. RNA 2 stated she was aware that if she did not document it, it was not done. c. A review of Resident 71's Record of Admission, indicated that the facility originally admitted the resident on 5/6/2009 and readmitted the resident on 8/12/2009, with diagnoses including severe intellectual disabilities (a condition characterized by significant limitations in both intellectual functioning and adaptive behavior), and tracheostomy (is an opening surgically created through the neck into the windpipe that provides an alternative airway for breathing). A review of Resident 71's H&P, dated 2/2/2022, indicated that the resident had normal bulk and tone, active, stands and walks; attends to simple non-verbal commands, able to do several Activities of Daily Living (ADL) related motor tasks. A review of Resident 71's MDS, dated [DATE], indicated that the resident usually makes self-understood and usually had the ability to understand others. The MDS indicated the resident required extensive assistance on dressing and total dependence on eating, toilet use, and personal hygiene. A review of Resident 71's Physician Orders, dated 10/7/2021, indicated an order to ambulate resident once daily by RNA. A review of Resident 71's Care Plan, dated 8/2022, indicated a that the resident had limitations in the functional range of motion in the following areas: full range of motion has no limitations. The goal of the care plan was for the resident not to have further decline in the functional range of motion in the said areas. A review of Resident 71's Restorative Charting Record, indicated missing initial of RNA 2 on 10/9/2022 on the ambulation of the resident once a day by RNA. During an interview on 10/27/2022, at 3:45 p.m., with RNA 2, the RNA 2 stated that she did the therapy to Resident 71 on 10/9/2022 but forgot to document it. RNA 2 stated she was aware that if she did not document it, it was not done. d. review of Resident 84's Record of Admission, indicated that the facility admitted the resident on 9/7/2021, with diagnoses including traumatic brain injury (results from a violent blow or jolt to the head or body) and dependence on respirator (breathing apparatus). A review of Resident 84's H&P, dated 9/7/2021, indicated that the resident was severely encephalopathic (any disease that affects the who/e brain and alters its structure or how it works, and causes changes in mental function), had no purposeful movement, and did not interact. A review of Resident 84's MDS, dated [DATE], indicated that the resident cannot make self-understood and has no ability to understand others. Resident 84 required total dependence on bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS stated the resident was on restorative nursing program for active range of motion. A review of Resident 84's Physician Orders, dated 9/10/2021, indicated an order for the resident to have passive range of motion to all extremities once a day by RNA. A review of Resident 84's Pediatric Physical Therapy Evaluation, dated 9/20/2021, indicated a treatment plan for therapeutic exercises and activities. A review of Resident 84's Care Plan, dated 9/2022, indicated that the resident had limitations in the functional range of motion in the following areas: minimum limitations on both knee, ankle, shoulder, and moderate limitation on both elbows. The goal of the care plan was for the resident not to have further decline in the functional range of motion in the said areas. A review of Resident 84's Restorative Charting Record, indicated missing initial of RNA 3 on 10/6/2022 and 10/7/2022 on passive range of motion to all extremities once a day by RNA. During an interview on 10/26/2022, at 10:04 a.m., with RNA 3, RNA 3 stated that she did the therapy to Resident 58 on 10/6/2022 and 10/7/2022 but forgot to document it. RNA 3 stated was aware that if she did not document it, it was not done. During an interview on 10/27/2022, at 4:29 p.m. with Director of Nursing (DON) and Director of Staff Development (DSD), the DON and DSD stated that RNA therapies should be documented timely at all times. Missing documentation in nursing means it was not done and has the potential to affect the range of motion (ROM) of the residents. During an interview on 10/28/2022, at 8:29 a.m., with Pediatric Nurse Manager (PNM), the PNM stated that RNA therapies should always be documented to show that the residents received the therapy. The PNM stated that RNAs were aware that if they don't document it, it was not done. During a concurrent interview and record review on 10/24/2022, at 2:29 p.m., with Restorative Nurse Assistant 1 (RNA 1), the RNA 1 reviewed with the surveyor the following missing entries for October 2022 on the Restorative Charting Record: Resident 58- 10/15/2022 Resident 60- 10/9/2022 Resident 71- 10/9/2022 Resident 84- 10/6/2022 and 10/7/2022 RNA 1 stated that initials of RNAs for residents and dates listed above were missing. A review of the facility's recent policy and procedure titled Range of Motion Exercises by RNA, revised date of 7/28/2022, indicated that the purpose of the policy is to prevent stiffness and pain in the joints, to retain as much joint function as possible, to maintain circulation. A Physician's order is necessary for passive range of motion exercises. A care plan will be initiated. RNA should initial Restorative Record daily when treatment is completed. Document notes in Weekly Summary Notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. During an observation and interview on 10/24/2022, at 9:55 a.m., with Pediatric Nurse Manager (PNM), observed a linen cart opened and unattended near Room E in the pediatric unit. The PNM stated that the linen cart should not be left opened for infection prevention purposes. During an observation and interview on 10/24/2022, at 12:20 p.m., with Certified Nursing Assistant 1 (CNA 1), observed a linen hamper near Room D opened and unattended. CNA 1 stated that the linen cart should be covered when not in use to prevent them from environmental contaminants that cause infection. During an observation and interview on 10/24/2022, at 2:04 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed a linen cart left open and unattended near Room C. LVN 1 stated that the cart should not be left open when not in use to prevent infection. During an observation and interview on 10/25/2022, at 10:23 a.m., with CNA 1, observed an opened and unattended linen cart near Room B. CNA 1 stated that that linen cart should be covered and not left open to environment due to infection issues. During an observation and interview on 10/26/2022, at 9:34 a.m., with Certified Nursing Assistant 2 (CNA 2), a linen cart open near Room A, an isolation room (a special room that keep residents with certain medical conditions separate from other residents while they receive medical care). CNA 2 stated that she should have not left the linen cart open for infection control. During an interview on 10/27/2022, at 4:29 p.m., with Director of Nursing (DON) and Director of Staff Development (DSD), the DON and the DSD stated that linen carts should always be covered when not in use to prevent contamination of the clean linen and spread of infection. A review of the facility's recent policy and procedure titled Linen Cart, review date of 7/28/2022, indicated that the purpose of this policy is to provide a guideline for the use of point of care resident care. A dust cover is placed on each clean linen cart to prevent dust and contamination. The dust cover can be lifted to remove linen. After linen is removed the dust cover will be closed to prevent contamination. f. A review of Resident 37's Record of admission indicated that the facility admitted the resident on 11/30/2014, with a readmission date of 7/19/2018, with diagnoses including chronic respiratory failure (when not enough oxygen passes from your lungs to your blood), tracheostomy (an opening surgically created through the neck into the wind pipe), and gastrointestinal dysmotility (a disorder where muscles of the digestive system become impaired leading to changes in the speed, strength, or coordination). A review of Resident 37's History and Physical (H&P), dated 8/11/2022, indicated that the resident was verbal, sits, walks with assistance, smiles and was interactive. A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/5/2022, indicated that the resident can make self-understood and can understand others. The MDS also indicated the resident had intact cognition (gaining of knowledge and understanding) and was totally dependent with feeding. A review of Resident 37's Physician Orders, indicated: - jejunostomy (surgery to create an opening into the small intestine from the outside of the body) tube feeding of Peptamen [NAME] (a nutritionally complete, easy to digest and easy to absorb formula) at 65 milliliters (ml- a metric unit of volume) per hour via pump for 20 hours to provide 1300 ml/1300 kilocalorie (kcals- is a standard of unit which is used to measure the energy content of foods and beverages) every 24 hours (off at 8 a.m., on at 12:00 p.m.) with order date of 4/8/2022. -flush feeding tube with 45 ml per hour water via pump for 22 hours to provide 990 ml/day for hydration, with order date of 9/9/2022. A review of Resident 37's Care Plan, dated 2/8/2022, indicated a presence of jejunostomy tube (JT- surgery to create an opening into the small intestine from the outside of the body). The resident was at risk for potential or actual infection related to aspiration and/or JT opening or stoma. Interventions indicated to prevent infection were check positioning of tubing and assess JT site for redness drainage, signs and symptoms of infection or irritation before administration of any care to resident. Secure all tubing properly with no traction prior to repositioning and turning resident and assess resident after care was rendered. During an observation on 10/24/2022, at 8:35 a.m., in Resident 37's room, found Resident 37's tube feeding lines were on the floor. Resident 37 stated that nobody educated her regarding the risk of keeping her feeding tubing on the floor. During an interview on 10/24/2022, at 2:57 p.m., with Assistant Pediatrics Nurse Manager (APNM), the APNM stated that the feeding tube should be off the floor to prevent infection. During an interview on 10/27/2022, at 4:29 p.m., with Director of Nursing (DON) and Director of Staff Development (DSD), both stated that the staff should keep the feeding tube off the floor due to infection issues. During an interview on 10/28/2022, at 8:29 a.m., with Pediatric Nurse Manger Pediatric Nurse Manager (PNM), the PNM stated that medical tubing should be off the floor due to infection. A review of the facility's recent policy and procedure titled Medical Device Tubing Placement, with a revise date of 7/28/2022, indicated that the purpose of this policy is to provide a guideline for the proper placement of medical device tubing to prevent contamination and safety. Medical device tubing will be placed in safe proximity to the resident. Tubing will be placed in a manner that prevents contamination from microbes. Tubing will be placed in a manner that will keep tubing from catching on other items, prevent pinching or pulling, and prevent contamination from microbes during transportation of the resident. g. A review of Resident 85's Record of Admission, indicated that the facility admitted the resident on 6/3/2022, with diagnoses including gastrostomy (is a surgical procedure used to insert a tube through the abdomen and into the stomach) and cutaneous abscess (a localized collection of pus) of abdominal wall. A review of Resident 85's History and Physical (H&P), dated 6/4/2022, indicated that the resident did not have the capacity to understand and make decisions. Resident 85 had status post drainage of abdominal abscess, several episodes of sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), extended spectrum beta-lactamase (ESBL- type of infection resistant with most antibiotics) and escherichia coli (E. Coli- bacteria that can cause severe bloody diarrhea), peritonitis (inflammation of the lining of the abdominal wall), on gastrostomy-jejunostomy tube (GJ Tube- goes through the abdomen and ends up in two different places, the stomach for medicine and ventilation, and the small intestine for feeding). A review of Resident 85's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/14/2022, indicated that the resident cannot make self-understood and had no ability to understand others. Resident 85 had severely impaired cognitive skills (gaining of knowledge and understanding) for daily decision-making. A review of Resident 85's Care Plan, dated 6/3/2022, indicated presence of jejunostomy tube (JT-a soft plastic tube placed through the skin of the abdomen into the midsection of the small intestine)/gastrostomy tube (GT- is a tube inserted through the belly that brings nutrition directly to the stomach) at risk for potential or actual infection related to aspiration and/or GT/JT opening or stoma (an opening on the abdomen) with a goal of resident will not always have infection at GT/JT site. During a medication administration observation on 10/27/2022, at 9:20 a.m., LVN 3 took the plunger out from the irrigation syringe and placed it directly on the side table of Resident 85. The plunger was later reattached to the barrel to flush the GJT with water. Asked LVN 3 to replace with a new irrigation syringe as LVN 3 already contaminated the current one. During an interview on 10/27/2022, at 9:30 a.m., with LVN 3, LVN 3 stated that she should have not used the irrigation syringe to flush the GJT tube with water because it is already contaminated. She stated that it is important to keep the irrigation syringe clean to prevent infection. During an interview n 10/27/2022, at 4:29 p.m., with Director of Nursing (DON) and Director of Staff Development (DSD), both stated that the irrigation syringe plunger should have not been placed directly on the side table to prevent infection. During an interview on 10/28/2022, at 8:29 a.m., with Pediatric Nurse Manager (PNM), the PNM stated that the LVN 3 should have not placed the irrigation syringe plunger directly on the side table to prevent infection. A review of the facility's recent policy and procedure titled Infection Control Plan, revised 7/28/2022, indicated that the infection control program has established policies and procedures for investigation, control, and prevention of transmission of disease and infections within the facility. The following apply: monitor staff performance to ensure policies and procedures for preventing the spread and occurrence of infection are properly executed. Provide a safe environment within the facility for the protection of residents, employees, physicians, and visitors. d. A review of Resident 78's admission Record indicated the facility admitted the resident on 12/27/2018 with diagnoses that included chronic respiratory failure (a condition where not enough oxygen passes from the lungs into the blood) and gastrostomy tube (g-tube, a surgical procedure for inserting a tube through the stomach for feeding or drainage). A review of Resident 78's History and Physical dated 2/16/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 78's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/16/2021 indicated Resident 78 was totally dependent on staff for mobility, dressing, eating, toilet use, and personal hygiene. During a Medication Pass Observation on 10/26/2022 at 9:13 a.m., RN 2 prepared Resident 78's medications at Medication Cart 7. A cup fell off the cart onto the floor and RN 2 picked up the cup and placed it back onto Medication Cart 7. RN 2 sanitized her hands and proceeded with the medication pass. During an observation and interview on 10/26/2022 at 10:01 a.m., RN 2 stated Resident 78's medication pass was complete. RN 2 removed the dirty cup off Medication Cart 7 and left the Adult Subacute Nursing Station with the dirty cup. RN 2 returned to Medication Cart 7 and used sanitizing wipes to clean the medication tray (a tray used to transport medications to bedside for administration), but not the surface of Medication Cart 7. RN 2 stated she picked the dirty cup off the floor and placed it on Medication Cart 7 because she did not know where else to place the cup. RN 2 stated she could have left the cup on the floor or placed it in a bag. RN 2 stated the importance of not placing a cup from the floor onto a medication cart was to reduce the risk of the spread of infection. RN 2 stated she would use sanitizing wipes to clean the surface of Medication Cart 7. During an interview on 10/27/2022 at 11:30 a.m., the Director of Nursing (DON) stated the RN should not have picked a cup off the floor and placed it on the medication cart. The DON stated the importance was because of infection control, safety, and preventing the spread of infection. A review of the facility policy and procedures titled, Infection Control Plan, last revised 9/2022, indicated the facility shall establish an Infection Control Program. The Program has established policies and procedures for investigation, control, and prevention of transmission of disease and infections within the facility. The objective of the Infection Control Plan includes providing a safe environment within the facility for the protection of residents, employees, physicians, and visitors. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by: 1. Failing to ensure that the suction canisters for three out of three sampled residents (Residents 33, 46, 72) were labeled with the date they were last changed. 2. Failing to ensure that a pair of gloves left on top of the overbed table was discarded for one out of one sampled resident (Resident 19). 3. Failing to ensure that the oxygen tubing connected to a resident's tracheostomy (a surgically created hole [stoma] on the windpipe [trachea] that provides an alternative airway for breathing) for one out of one sampled resident (Resident 73) was changed. These deficient practices had the potential for contamination of resident's care equipment and placed Residents 19, 33, 46, 72, and 73 at risk for infection. 4. Failing to ensure Registered Nurse 2 (RN 2) did not pick a cup up off the floor and place it on Medication Cart 7 for one of four sampled residents (Resident 78), investigated during a Medication Pass Observation. This deficient practice had the potential to transmit infectious microorganisms and placed the residents and staff at risk for infection. 5. Failing to keep linen carts always covered and free from environmental contaminants on five (5) occasions. This deficient practice had the potential to spread infection in the facility. 6. Failing to keep the feeding tube off the floor for of one out of seventeen sampled residents (Resident 37). This deficient practice had the potential to spread infection to Resident 37. 7. Failing to keep the irrigation syringe (used to irrigate enteral tube [way of delivering nutrition directly to the stomach through tube feeding] for feeding) clean for one out of two sampled residents (Resident 85) by placing the plunger (a closely fitted device that is pushed in or pulled out of the barrel to insert or extract fluid) directly on the side table of Resident 85 instead of placing it on the clean tray. This deficient practice had the potential to spread infection to Resident 85. 8. Failing to ensure Respiratory Therapist 4 (RT 4) and Respiratory Therapist 5 (RT 5) performed hand hygiene after doffing (taking off) contaminated gloves upon performing oral suctioning (procedure to clear and remove secretions from the mouth) and prior to donning (putting on) sterile gloves for deep suctioning (procedure for clearing mucus from deeper respiratory structures or artificial airways) for one of five sampled residents (Resident 49). 9. Failing to ensure the suction canister (temporary storage container for secretions or fluids removed from the body) and tubing were labeled with the date of replacement for one of five sampled residents (Resident 49). These deficient practices had the potential to transmit infectious microorganisms and placed the residents and staff at risk for infection. 10. Failing to ensure a resident's suction canister was changed per physician's orders for one of one sampled resident (Resident 30). This deficient practice had the potential for contamination of resident's equipment and placed the resident at risk for infection. Findings: a.1. A review of Resident 33's Record of admission indicated the facility originally admitted the resident on 10/13/2008 and readmitted the resident on 2/14/2019 with diagnoses including chronic respiratory failure (a long-term condition in which the lungs have a hard time loading blood with oxygen), dependence on respirator (a machine that helps patients breathe when they cannot breathe on their own), and tracheostomy. A review if Resident 33's History and Physical dated 2/2/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 33's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/1/2022, indicated the resident had a moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 10/24/2022 at 11:02 a.m., Resident 33's suction canister did not have a label indicating when it was last changed. a.2. A review of Resident 46's Record of admission indicated the facility admitted the resident on 3/26/2015 and readmitted the resident on 7/14/2021 with diagnoses including chronic respiratory failure, dependence on respirator, tracheostomy, and asthma (a condition in which your airways narrow and swell and may produce extra mucus). A review of Resident 46's History and Physical dated 7/12/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 46's Minimum Data Set, dated [DATE], indicated the resident's cognition was severely impaired and was totally dependent on staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 10/24/2022 at 11:04 a.m., Resident 46's suction canister did not have a label indicating when it was last changed. a.3. A review of Resident 72's Record of admission indicated the facility admitted the resident on 3/30/2017 with diagnoses including chronic respiratory failure and tracheostomy. A review of Resident 72's History and Physical dated 3/23/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 72's Minimum Data Set, dated [DATE], indicated the resident was able to understand others and made himself understood, and had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated Resident 72 was totally dependent on staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 10/24/2022 at 11:04 a.m., Resident 72's suction canister did not have a label indicating when it was last changed. During a concurrent observation and interview on 10/24/2022 at 11:10 a.m., Licensed Vocational Nurse 7 (LVN 7) confirmed that the suction canisters did not indicate the last time they were changed. LVN 7 further stated it was important that suction canisters should be labeled with the residents' names and the dates they were changed as it is an infection control issue. During an interview on 10/24/2022 11:15 a.m., Respiratory Therapist 6 (RT 6) stated that suction canisters and tubings are changed by the Certified Nursing Assistants (CNAs) twice a week on Tuesdays and Fridays. RT 6 stated it was important to label the canisters with residents' names and dates they were changed for infection control purposes. During an interview on 10/27/2022 at 3:40 p.m., the Director of Nursing (DON), stated suction canisters are changed by night shift certified nursing assistants (CNAs) twice a week on Tuesdays and Fridays. The DON stated the canisters should have indicated the dates they were last changed to prevent placing the residents at risk for infection. A review of the facility's policy and procedure titled Suction Canister and Tubing Change, last reviewed on 7/28/2022, indicated that the suction canister will be changed every Tuesday and Friday and as needed by the night shift CNAs and will be labeled with the resident's name and the date the canister was changed. b. A review of Resident 19's Record of admission indicated the facility admitted the resident on 9/27/2016 with diagnoses including chronic respiratory failure, acute respiratory distress syndrome (a condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen), tracheostomy, gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that blocks airflow and make it difficult to breathe), and anoxic brain damage (harm to the brain due to a lack of oxygen). A review of Resident 19's History and Physical dated 9/6/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 19's Minimum Data Set, dated [DATE], indicated the resident was in a persistent vegetative state (absence of responsiveness and awareness) and was totally dependent on staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During and observation on 10/24/2022 at 10:45 a.m., observed a pair of used gloves on top of Resident 19's overbed table next to a basket of toiletries. During a concurrent observation and interview on 10/24/2022 at 10:52 a.m., Licensed Vocational Nurse 7 (LVN 7) confirmed the presence of used gloves on top of the overbed table and stated not sure who left the used gloves. LVN 7 further stated it should have been discarded as it is an infection control issue and can cross contaminate (unintentional transfer of bacteria/germs or other contaminants from one surface to another) Resident 19's toiletries. During an interview on 10/27/2022 at 4:24 p.m., the Director of Nursing (DON) stated the gloves should have been discarded after use. The DON stated the importance was because of infection control, safety, and preventing the spread of infection. A review of the facility's policy and procedure titled, Infection Control Plan, last revised 9/2022, indicated the facility shall establish an Infection Control Program. The Program has established policies and procedures for investigation, control, and prevention of transmission of disease and infections within the facility. The objective of the Infection Control Plan includes providing a safe environment within the facility for the protection of residents, employees, physicians, and visitors. c. A review of Resident 73's Record of admission indicated the facility admitted the resident on 8/4/2021 and readmitted the resident on 8/6/2022 with diagnoses including chronic respiratory failure, dependence on respirator, tracheostomy, and gastrostomy. A review if Resident 73's History and Physical dated 8/8/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 73's Minimum Data Set, dated [DATE], indicated the resident was in a persistent vegetative state and was totally dependent on staff with activities of daily living. During an observation, on 10/26/2022 at 8:04 a.m., observed Resident 73 lying in bed with tracheostomy connected to oxygen at 4.5 liters per minute via tracheostomy mask (a medical device with tubing used to deliver oxygen). Upon inspection of the resident`s environment and equipment, observed that the oxygen tubing was labeled with the date of 10/16/2022. During an interview on 10/26/2022 at 8:08 a.m., Respiratory Therapist 3 (RT 3) validated the oxygen tubing indicated a date of 10/16/2022 and stated the tubing should have been changed as it has already been 10 days since it was last changed, placing the resident at risk for infection. RT 3 also stated oxygen tubings should be changed weekly per policy for infection control reasons. During a concurrent interview and record review of Resident 73's Medication Administration Record (MAR) on 10/26/2022 at 8:20 a.m., Licensed Vocational Nurse 9 (LVN 9) confirmed weekly changing of oxygen tubing was not indicated in the MAR. During a concurrent interview and record review of Resident 73's Treatment Administration Record (TAR) on 10/26/2022 at 8:25 a.m., Treatment Nurse 1 (TN 1) confirmed weekly changing of oxygen tubing was not indicated in the TAR. During a record review on 10/26/2022 at 8:35 a.m. with RTD, Resident 73's Physician's Orders did not indicate an order to change oxygen tubing weekly and as needed. During an interview on 10/26/2022 at 8:30 a.m., the Respiratory Therapy Director (RTD) stated that all disposable respiratory equipment which includes oxygen tubing for non-respirator dependent residents are changed every 7 days and as needed per facility policy. The RTD also stated changing of tubing for non-respirator dependent residents were not documented in the MAR, TAR, or Respiratory Treatment Record as they were not in the physician's orders. The RTD also stated that Resident 73's oxygen tubing should have been changed per facility policy as it places Resident 73 at risk for infection. During an interview on 10/27/2022 at 4:35 p.m., the Director of Nursing (DON) stated that oxygen tubing for tracheostomy is changed every 7 days and as needed per facility policy. The DON stated Resident 73's oxygen/aerosol tubing should have been changed after 7 days to prevent development of infection. A review of the facility's policy and procedure titled, Equipment Changing-Shift Responsibilities, last reviewed on 7/28/2022 and last revised on 10/26/2022, indicated a purpose that the Department of Respiratory Care will designate equipment changing responsibilities to the Respiratory Care Practitioners assigned to a particular shift and work area to adhere to the Infection Control guidelines. The policy and procedure also indicated all tubing, drainage bags, masks, and adapters are changed every 7 days and as needed. h. A review of Resident 49's Record of admission indicated the facility admitted the resident on 9/20/2011, and most recently readmitted the resident on 7/5/2022, with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), encounter for attention to tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and dependence on ventilator (machine that helps patients breathe when they cannot breathe on their own). A review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2022, indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS further indicated Resident 49 was totally dependent on staff for activities of daily living (ADL - activities related to personal care) that includes bed mobility, transfers, dressing, toilet use, and personal hygiene. During an observation, on 10/27/2022 at 12:56 p.m., observed RT 4 provide oral suctioning for Resident 49 using a Yankauer (a rigid oral suctioning tool). Observed RT 4 doff gloves and don new sterile gloves without performing hand hygiene. Observed RT 4 perform deep suctioning with suction catheter via tracheostomy. During an interview, on 10/27/2022 at 1:03 p.m., RT 4 confirmed that she did not perform hand hygiene in between changing her gloves when she doffed her used gloves upon providing oral suctioning and prior to donning her sterile gloves for deep suctioning. RT 4 stated she should have performed hand hygiene with an alcohol-based hand sanitizer (ABHS) or washed her hands with soap and water for at least 20 seconds. During an observation, on 10/28/2022 at 10:16 a.m., observed RT 5 provide oral suctioning for Resident 49. Observed RT 5 doff and discard the used gloves in trash bin. Observed RT 5 then pull Resident 49's curtain and proceed to don sterile gloves without performing hand hygiene. Observed RT 5 removing suction catheter from the suction kit and provide deep suctioning via tracheostomy. During an interview, on 10/28/2022 at 10:43 a.m., RT 5 verified he did not perform hand hygiene in between changing gloves. RT 5 stated he should have performed hand hygiene with either ABHS or soap and water upon doffing his gloves that were used for oral suctioning and prior to donning his sterile gloves for deep suctioning. RT 5 further stated hand hygiene should be performed for infection control to maintain sterile technique when providing deep suctioning for residents. During an interview, on 10/28/2022 at 1:55 p.m., the Infection Preventionist (IP) stated hand hygiene is required before gloves are worn and once gloves are removed upon providing care. The IP also stated hand hygiene should be performed first thing whenever sterile procedures such as deep suctioning is provided for residents and confirmed RT 4 and RT 5 should have performed hand hygiene in between changing gloves since they were coming from using contaminated Yankauer to using a sterile suction catheter. The IP stated failure to perform hand hygiene prior to providing a deep suctioning can potentially contaminate the sterile gloves, making the procedure unsterile. The IP stated the purpose of hand hygiene is to sanitize the hands to prevent cross contamination among residents and staff for infection control. The IP further stated failure to perform hand hygiene is the number one reason why people get infections. A review of the facility's policy and procedure titled, Handwashing and Sanitizing, last reviewed on 7/28/2022, indicated to hand washing needs to be done before and after resident contact, between clean and dirty procedures and when hands are visibly soiled. The policy and procedure indicated hand washing will be done even when staff has donned gloves during a procedure since hands may become contaminated even with glove use and may transfer organisms to a fresh set of gloves. i. A review of Resident 49's Record of admission indicated the facility admitted the resident on 9/20/2011, and most recently readmitted the resident on 7/5/2022, with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), encounter for attention to tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and dependence on ventilator (machine that helps patients breathe when they cannot breathe on their own). A review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2022, indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS further indicated Resident 49 is totally dependent on staff for activities of daily living (ADL - activities related to personal care) that includes bed mobility, transfers, dressing, toilet use, and personal hygiene. During an observation, on 10/24/2022 at 10:02 a.m., observed Resident 49's suction canister half-full with light green secretions. Observed the suction canister and tubing with no date labeled. During a concurrent observation and interview, on 10/24/2022 at 11:35 a.m., Respiratory Therapist 2 (RT 2) observed and confirmed Resident 49's suction canister and tubing were not labeled and dated. RT 2 stated the suction canister along with the tubing are changed at least once a week on Tuesdays by the certified nursing assistants (CNAs) working night shift. RT 2 stated the staff who changed the suction canister and tubing should have labeled them with the date when it is being replaced to know when it needs to be changed again for infection control. During an interview, on 10/27/2022 at 1:45 p.m., the Director of Nursing (DON) stated the suction canister and tubing should be changed twice a week every Tuesdays and Fridays for both adult and pediatric residents per facility policy. The DON stated the night shift CNAs are responsible for changing the canister along with the tubing but the licensed nurses can also change them as needed if the CNAs are busy. The DON verified both the suction canister and tubing should be labeled with the resident's name and date any time they are replaced per facility policy. The DON further stated it is important to label with the resident's name and date for infection control[TRUNCATED]

Based on interview and record review, the failed to monitor and document antibiotic (medication used to treat bacterial infections) use for one of three sampled residents (Resident 79). This deficient practice had the potential for the resident to receive an inappropriate antibiotic and develop antibiotic resistance. Findings: A review of Resident 79's Record of admission indicated the facility admitted the resident on 3/9/2017 with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), dependence on ventilator (machine that helps patients breathe when they cannot breathe on their own), and hypoxic ischemic encephalopathy (brain dysfunction caused by lack of blood flow and oxygen to the brain). A review of Resident 79's History and Physical Progress Note, dated 11/1/2021, indicated resident had a history of ethylmalonic encephalopathy (inherited early onset progressive disorder affecting the brain, gastrointestinal tract, and blood vessels). A review of Resident 79's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/12/2022, indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS further indicated Resident 79 was totally dependent on staff for activities of daily living (ADL - activities related to personal care) that included bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 79's physician's order, ordered on 4/19/2017, indicated an order for metronidazole (antibiotic used for treatment of bacterial infections) 187 milligrams (mg-unit of measure) via gastrostomy tube (g-tube, feeding tube placed through the abdomen into the stomach to provide nutrition and medication) every eight hours (q8h) for loose stool. A review of Resident 79's Medication Record from 4/2017 indicated metronidazole 187 mg was administered via g-tube q8h from 4/19/2017 to 4/30/2017. A review of Resident 79's Medication Record from 7/2020 indicated metronidazole 187 mg was administered via g-tube q8h from 7/1/2020 to 7/31/2020. A review of Resident 79's Medication Record from October 2022 indicated Metronidazole 187 mg was administered via g-tube q8h from 10/1/2022 to 10/28/2022. A review of the Consultant Pharmacist's Medication Regimen Review (MRR): Listing of Residents Reviewed with No Recommendations from 2/2022 to 10/2022 indicated there were no recommendations for Resident 79 during the consultant pharmacist's visit. During a concurrent interview and record review, on 10/28/2022 at 12:47 p.m., the Infection Preventionist (IP) reviewed Resident 79's physician's order and verified the resident was currently on metronidazole 187 mg via g-tube scheduled every eight hours for loose stools, ordered on 4/19/2017. The IP then reviewed resident antibiotic log for pediatrics for 9/2022 and verified that Resident 79 was not on the list of residents being monitored and tracked for antibiotic use that would indicate the diagnosis, the antibiotic the resident is receiving, start and stop date, signs and symptoms, and lab work. The IP stated he was unaware that Resident 79 was receiving metronidazole and confirmed that the resident was not being monitored for antibiotic use. The IP further verified the resident has been on the medication since 4/19/2017 and confirmed loose stools in not an appropriate indication for giving antibiotics and does not know why the resident has been on it this long. The IP stated Resident 79 should have been on the pediatric antibiotic list and confirmed it was missed during the weekly chart audits. The IP stated that he and the IP assistant complete a weekly chart audit checking to see what antibiotic the resident is receiving and making sure there is a physician's order and care plan for the antibiotic. The IP stated they also check to ensure that the ordered antibiotic appears on the Medication Administration Record (MAR) and that the antibiotic is appropriate for the resident based on the lab. The IP stated he determines if the ordered antibiotic is appropriate for the resident by checking to see if the microorganism from the culture is susceptible to the antibiotic. The IP stated he would notify the physician if it is not susceptible and the physician will give a new order making changes to the antibiotic if needed based on the cultures. The IP further stated pharmacy reviews and provides oversight for antibiotic use, makes recommendations, and discusses in the antibiotic stewardship quarterly meetings and as needed with the Director of Nursing (DON), Administrator, Medical Director, and IP. The IP stated Resident 79 should have been monitored and tracked for antibiotic use to prevent giving unnecessary medications and to prevent creating multidrug resistant organisms (MDRO) from overuse of antibiotics. During an interview, on 10/31/2022 at 8:08 a.m., the Pharmacist (Pharm) stated she conducts MRR once a month and reviews the medications for every resident in the facility including pediatric residents. The Pharm stated she would review the order recap (summary) and look for newly ordered medications and try to identify irregularities that include reviewing for appropriate indication, dose, and duration. The Pharm stated she monitors and evaluates antibiotic use and checks for the right indication, dosing, length of therapy, and for any possible drug interactions. The Pharm verified Resident 79's physician order for metronidazole 187 mg via g-tube for loose stools with a start date of 4/19/2017. The Pharm stated a recommendation for metronidazole was last made in 6/2017 by the previous pharmacist questioning the length of therapy and asking what the stop date was. The response from the physician was that the antibiotic was recommended by Resident 79's geneticist for maintenance for the diagnosis of ethylmalonic encephalopathy. Upon reviewing the order, the Pharm verified Resident 79's order for metronidazole does not have a duration indicating the length of therapy and stated antibiotic orders should have a duration and a stop date to justify its use. The Pharm explained the duration for metronidazole normally ranges anywhere from five to 14 days depending on what is being treated. The Pharm also confirmed loose stools is not an adequate indication for why the antibiotic should be given and stated the order should have been clarified with the physician. The Pharm stated that she was aware of the irregularities regarding Resident 79's metronidazole order and thought it was strange. However, the Pharm confirmed she did not make any recommendations and report the irregularities concerning Resident 79's metronidazole since she began as the consultant pharmacist for the facility from 1/2022. The Pharm stated the irregularities should have been reported to the Director of Nursing (DON) to follow up with the physician to clarify the order and if the resident still needs to be on the antibiotic for maintenance since the last recommendation made in 6/2017 by the previous pharmacist. The Pharm stated long term antibiotic use can potentially result in changes in the gut flora (bacteria and other organisms that live inside the intestines) and can lead to antibiotic resistance. During an interview, on 10/31/2022 at 8:58 a.m., the DON confirmed she did not receive a written report of pharmacy recommendation regarding Resident 79's metronidazole order and verified there were no recommendations from pharmacy for Resident 79 from 1/2022 to 10/2022. The DON stated she is part of the antibiotic stewardship team and stated they usually meet once a month and quarterly. The DON stated the facility has a list of patients who are on antibiotic therapy and discuss what patients are on antibiotic and if ordered antibiotic is appropriate for the resident and should be continued during the meetings. The DON confirmed Resident 79's metronidazole was not brought up during the meetings as far as she can recall. The DON stated the physician's order for antibiotics should include the diagnosis or infection to indicate the reason for why it is being given and confirmed loose stool indicated in Resident 79's metronidazole order is not an adequate indication. The DON stated antibiotic orders should also include a duration specifying a stop date. The DON stated the licensed nurses should have identified Resident 79's order for metronidazole did not have a stop date and notified the physician to decide if the antibiotic is still needed and should be continued or discontinued. The DON further stated it was missed and overlooked by everyone including the licensed nurses, physician, infection preventionist (IP), and the pharmacist. The DON stated the IP and the IP assistant audits the chart at least once per week to identify residents on antibiotics and to monitor for the right indication, dose, duration, drug interactions and effectiveness of the antibiotic. The DON stated the importance of ensuring that the right antibiotic with a stop date is administered to residents for a specific infection or diagnosis to prevent side effects and life-threatening adverse reactions and to prevent the residents from developing antibiotic resistance from long term antibiotic use which can lead to MDRO. A review of the facility's policy and procedure titled, Core Elements of Antibiotic Stewardship, last reviewed on 7/28/2022, indicated the purpose of the policy is to coordinate interventions designed to promote and measure the appropriate use of antimicrobial agents. The policy and procedure indicated the infection preventionist will monitor the use of antibiotics for residents, gather data, follow laboratory results, and ensure that the appropriate antibiotic is used. The policy and procedure further indicated the pharmacy consultant will evaluate the use of antibiotics for appropriate use, scheduling, and dosing and will provide oversight through quality assurance activities such as medication review, reporting of antibiotic use and appropriate antibiotic usage. A review of the facility's policy and procedure titled, Antibiotic Therapy, last reviewed on 7/28/2022, indicated the physician's order for antibiotics must include the following: the name, dose, frequency, duration, and the reason for the antibiotic.